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THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


BOUOHT  OP 

Chicago  Medical  Bool(  Co. 

CoD^reftB  A  llonore  Sts. 
Chicago 


Digitized  by  the  Internet  Arciiive 

in  2007  with  funding  from 

IVIicrosoft  Corporation 


http://www.archive.org/details/cataractextractiOOherbiala 


CATARACT  EXTRACTION 


CATARACT  EXTRACTION 


H.     HERBERT,     F.R.C.S. 

Late  Lieutexant-Coloxel.  I.M.S.,  Professor  of  Ophthalmic  Medicixe  and 
Surgery,  Graxt  Medical  College,  axd  ix  charge  of  the  Sir 

COWASJEE  JEHAXGIR  OPHTHALMIC    HOSPITAL,    BOMBAY 


NEW    YORK 
WILLIAM    WOOD    &    COMPANY 

MDCCgCVIII 


W 


// 


PREFACE  f^oS^ 

The  writing  of  this  book  has  been  laboured  a;i(^x^w. 
The  volume  embodies  an  experience  of  about  fiv^^ousand 
extractions.  This  is  a  comparatively  small  experience  for 
an  ophthalmic  surgeon  of  standing  in  India.  But  on  this 
account  the  material  has  been,  perhaps,  more  completely 
handled  and  investigated  than  if  the  numbers  had  been 
larger.  In  busy  seasons  Indian  surgeons  have  barely  time 
to  perform  their  operations,  and  can  see  little  or  nothing 
of  the  cases  afterwards.  For  years  I  have  jotted  down  facts 
and  ideas  regularly  as  they  came,  and  have  developed  them 
for  teaching  purposes,  both  in  hospital  and  in  the  lecture 
theatre.  The  present  work  has,  in  a  sense,  grown  out  of 
an  earlier  publication — '  The  Practical  Details  of  Cataract 
Extraction ' — of  which  two  editions  were  published  in 
1903.  A  large  portion  of  Chapter  I,  and  a  few  isolated 
paragraphs  and  sentences  elsewhere,  have  been  taken  with 
little  or  no  change  into  the  new  publication.  But  for  the 
most  part  this  larger  effort  consists  of  new  material  col- 
lected from  a  wider  experience.  An  attempt  has  been 
made  to  present  an  up-to-date  treatise,  as  complete  as 
desirable  from  a  practical  point  of  view,  and  likely  to  be 
of  service  even  to  older  surgeons  who  may  have  already 
formed  their  opinions  and  established  their  procedure. 
The  historical  side  of  the  subject  has  alone  been  very 
imperfectly  dealt  with. 

Nottingham, 

June,  igo8. 


CONTENTS 

CHAPTER  I 
'  OPERABLE  CATARACT 

PAGES 

Definitions — Progressive  cataracts — Stages — Varieties — Lique- 
fying, shrinking,  and  hypersclerotic  cataracts — Complicated 
and  traumatic  cataracts — Operability — Artificial  ripening — 
Volume  of  cataractous  lenses  .  -  .  .     i — 22 

CHAPTER  II 

DESCRIPTION  OF  THE  OPERATION 

Historical  outline — Instruments — General  arrangements — Pre- 
paration of  the  patient — Preliminaries — Initial  steps — The 
combined  operation — The  section — The  iridectomy—  The 
opening  of  the  capsule — The  delivery  of  the  lens — Toilet  of 
the  eye — The  dressing — After-course  and  after-treatment   23—159 

CHAPTER  III 

EXPULSIVE      HAEMORRHAGE.       VITREOUS     ACCI 

DENTS         --.-...     160—177 

CHAPTER  IV 

VARIATIONS  IN  PROCEDURE,  AND  THEIR  VALUE 

General  preliminary  and  preparatory  details — Fixation — The 
section — Simple  extraction — Peripheral  iridectomy — Pre- 
liminary iridectomy — Other  modes  of  opening  the  capsule — 
Intraocular  irrigation — The  open  treatment  of  the  wound — 
Extraction  of  the  lens  together  with  its  capsule — Asepsis — 
Results   -------     178 — 280 


viii  Contents 

CHAPTER  V 
AFTER-COMPLICATIONS 

PAGES 

The  infective  processes  and  non-infective  reactions— Various 
forms  of  corneal  opacity — Exfoliation  of  corneal  epithelium 
— Anteflexion  of  the  corneal  flap — Filamentous  keratitis — 
Conjunctivitis — Acute  dermatitis — Spastic  entropion — Pro- 
lapse and  incarceration  of  iris — Prolapse  and  loss  of  vitreous 
— Impaction  of  capsule — Intraocular  htemorrhage — Delayed 
union  and  reopening  of  the  wound — Transient  detachment 
of  the  choroid — Mental  disturbance  — Flatulent  distension  of 
the  abdomen — Secondary  glaucoma — After- cataract — De- 
tachment of  retina  .  -  _  -  .     281 — ^364 

CHAPTER  VI 

COMPLICATED  AND  SOFT  CATARACTS 

Cataract  with  glaucoma — Cataract  secondary  to  irido-cyclitis — 
Removal  of  the  transparent  lens  in  high  myopia — Dislo- 
cated lenses— The  extraction  of  soft  cataract — Suction     365 — 385 

Index  ...._..    387—391 


ERRATA 

Page  104,  line  4,  delete  the  article  at  the  beginning  of  the  line. 

Page  107,  line  8,  for  "  is  "  read  "  was." 

Page  120,  line  29,  insert  "is  made  "  after  "  counter-pressure." 

Page  124,  line  10,  for  final  "  by  "  read  "of." 

Page  140,  line  ig,  for  "is  "  read  "are." 

Page  142,  footnote,  for  "  adopted  "  read  "  adapted." 

Page  203,  line  8,  for  "cubic  millimetres  "  read  "centimetre." 

Page  227,  last  line,  for  "  nuclei  "  read  "  nucleus." 

Page  232,  line  3,  for  "  Von  "  read  "  Van." 

Page  237,  line  34,  for  "  overripes  "  read  "overripe." 

Also  a  few  '  split  infinitives  '  have  escaped  detection 


CATARACT    EXTRACTION 


CHAPTER  I 
OPERABLE  CATARACT 


^ 


Definitions — Progressive  cataracts — Stages — Varieties  —  Liquefying, 
shrinking,  and  hypersclerotic  cataracts — Complicated  and  trau- 
matic cataracts  —  Operability  —  Artificial  ripening — Volume  of 
cataractous  lenses. 

The  term  *  cataract '  denotes  opacity  of  the  crystalline 
lens.  Its  nature  and  varieties  will  be  entered  into  here 
only  so  far  as  appears  necessary  from  their  bearing  on 
treatment.  The  term  '  capsular  cataract  '  does  not 
ordinarily  indicate  loss  of  transparency  of  the  true  capsule 
of  the  lens.  It  is  applied  to  proliferations  of  the  lens  cells 
which  normally  line  only  the  anterior  capsule,  but  which, 
in  some  cataractous  lenses,  may  extend  around  over  the 
whole  of  the  posterior  capsule  also.  The  new  formations 
are  within  the  true  capsule,  but  are  inseparable  from  it. 
'  After-cataract ' — also  spoken  of  as  *  secondary  cataract,' 
thus  unnecessarily  introducing  confusion  with  cataract 
secondary  to  other  diseases  of  the  eye — is  the  opacity 
which  frequently  interferes  with  vision  after  the  removal 
of  the  lens.  It  may  be  capsular  cataract  in  the  above 
sense,  or  even  possibly  opacity  of  the  true  capsule,  or  there 
may  be  opaque  cortex  left  imprisoned  between  the  layers 
of  capsule.  The  name  is  also  less  correctly  applied  to 
deposit  on  the  front  of  the  capsule — i.e.,  strictly  speaking, 
pupillary  membrane. 


U  "^v^ 


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Cataract  Extraction 


The  cataract  may  be  partial,  affecting  only /ortions  of 
lens  substance,  or  general.  Completeness/  or  a  near 
approach  to  it,  is  considered  generally /necessary  for 
treatment  by  extraction  of  the  lens,  wHicK  is  almost  the 
only  recognized  measure*  nowadays  fo^lenses  with  hard 
nuclei,  absorption  of  opaque  lens  matter  being  practicable 
in  young  persons  with  lenses  still  soft  throughout. 

Progressive  Cataracts,  those  which  become  general  or 
complete,  are  classified  thus  : 

I.  Primary,  independent  of  other  recognizable  affection 
of  the  eye.  This  includes  by  far  the  largest  group,  the 
purely  idiopathic  cases,  mostly  senile,  yet  occurring  at 
any  age.  Senility  in  this  connexion  is  in  India  a  very 
relative  tej-m,  since  the  cases  begin  to  be  numerous  after 
fortyySars  of  age.f  There  are  also  the  cataracts  develop- 
ing in  diabetes,  nephritis,  tetany,  and  ergotism,  and 
glass-blower's  and  bottle-finisher's  cataract. 

II.  Complicated,  or  secondary  to  obvious  disease  of 
the  eye — e.g.,  in  high  myopia  with  disease  of  the  vitreous 
and  choroidal  changes,  and  in  late  stages  of  retinitis 
pigmentosa.  Or  due  to  advanced  glaucoma,  or  to  the 
effects  of  irido-cyclitis,  atrophy  of  ciliary  body,  and 
posterior  synechiae.     Or  a  result  of  dislocation  of  the  lens. 

III.  Traumatic,  due  to  penetrating  wound,  or  to 
rupture  of  the  capsule,  t     With  these  may  be  grouped  the 

*  Depression  and  reclination  of  cataracts,  still  very  frequently  per- 
formed  by  vatds  and^aiims  in  India'  may  in  very  rare  instances  be 


the  only  treatment  a<vailable. 

t  It  is  not  true,  however,  of  Bombay  that  "  the  majority  of  cataract 
patients  come  to  operation  at  forty  years  or  thereabouts"  (Hirsch- 
berg,  speaking  of  the  East  hidies  generally,  quoted  in  Norris  and 
Oliver's  '  System,'  iv.  324).  Hn  Bombay  there  are,  roughly  speaking, 
twice  as-many  patients  over  fifty  as  under  fifty  years  of  aga.  Probably 
in  the  \Qtense  Jieat  and  glare  of  the  northern  plains  of  India  cataract 
comes  earlierJ 

J  The  few  traumatic  cataracts  recorded  without  evident  rupture  of 
capsule  have  been  paitial,  and  in  some  cases  transient. 


Operable  Cataract  3 

lenses  needled  preparatory  to  removal  in  high  myopia,  or 
for  lamellar  cataract,  etc. 

The  Stages  into  which  it  is  cfonvp«ient  to  divide  the 
development  of  cataract  are :  /m^ncipient,  (2)  unripe^'^ 
(3)  ripe  or  mature,  and  (4)  overripe.  Cataracts  are  much 
more  often  allowed  to  become  overripe  in  India  than  in 
Europe.  It  may  be  roughly  stated  that  in  the  incipient 
stage  they  often  require  a  dilated  pupil  or  dark  room 
examination  for  their  certain  detection — for  their  dis- 
tinction, for  instance,  from  simple  senile  sclerosis.  Unripe 
cataracts  are  at  once  recognizable  with  the  naked  eye, 
but  there  is  still  some  transparent  or  semi-transparent 
cortical  matter  remaining.  In  the  ripe  stage  the  whole 
lens  looks  opaque.  Overripeness  is  shown  by  certain 
secondary  changes,  and  by  the  formation  of  capsular 
opacities,  recognizable  by  being  whiter  than  any  super- 
ficial opacity  of  lens  substance. 

The  term  '  ripeness,'  indicating  complete  opacity  of  the  lens, 
implies  also  that  the  whole  lens  can  be  removed  from  its  capsule 
easily, "  like  a  ripe  fruit  out  of  its  shell,"  and  that  the  cataract  is 
therefore  ready  for  operation.  The  term  is  still  retained  to 
denote  the  fullness  of  the  cataractous  change,  though  it  has 
long  been  recognized  that  many  lenses  are  fit  for  removal  while 
still  preserving  much  of  their  transparency.  According  to 
Hirschberg,"  this  style  of  indicating  the  stage  of  the  cataractous 
process  originated  before  the  operation  of  extraction  was  known 
— at  a  time,  therefore,  when  lenses  were  merely  depressed. 

The  Varieties  of  cataract  formation  are  not  so  clearly 
separable,  combinations  and  connecting-links  serving  to 
fill  in  gaps  between  the  different  typical  degenerations. 
And  attempts  which  have  been  made  to  classify  cataracts 
from  clinical  appearances  alone  have  led  to  some  con- 
fusion, owing  to  failure  to  distinguish  between  stages  and 

*  Cbl.f.pr.  ^.,  xiv  (1890),  210. 

I — 2 


4  Cataract  Extraction 

processes.  Yet  clinical  grouping  is  decidedly  useful  to 
indicate  important  practical  differences  in  the  shape  and 
size  of  the  lens,  and  in  the  consistence  and  cohesion  of  its 
substance,  and  in  the  elasticity  and  toughness  of  the 
capsule. 

A  sufficiently  clear  distinction  has  not  been  maintained 
between  th^  processes  at  work  in  senile  cataract  forma- 
tion. Three  marrttypes  of  change  are  clearly  recognizable — 
the  first  progressing  through  liquefaction  towards  ultimate 
absorption ;  the  second  leading,  by  slow  shrinkage  of  the 
lens,  to  the  formation  of  a  more  or  less  flattened  disc 
enclosed  in  very  opaque  capsule ;  the  third  forming  the 
comparatively  uncommon  black  cataract.  These  divisions 
are  the  same  as  those  made  by  A.  Graefe*  in  1884,  but 
they  read  differently,  because  he  did  not  follow  the  changes 
in  their  various  stages. 

I.  Liquefying  Cataracts. — We  have  been  long  familiar 
with  the  changes  which,  in  traumatic  cataract,  follow 
from  the  simple  admission  of  aqueous  through  a  rent  or 
cut  in  the  capsule.  Bluish  -  white  opacity,  swelling, 
softening,  breaking  down  and  disappearance  of  non- 
sclerosed  lens  substance  takes  place. 

In  many  idiopathic  cataracts  similar  changes  are  so 
early  and  pronounced  that  they  constitute  the  main 
clinical  features.  But  the  fluid  which  gains  an  entrance, 
and  in  which  the  broken-down  cortex  is  suspended, 
remains  for  long  unabsorbed.  It  does  not  disappear 
rapidly,  as  in  traumatic  cataract,  where  the  opening  in  the 
capsule  precludes  an  accumulation  of  fluid  contents. 
I  It  seems  that  the  admission  of  aqueous  may  be  due  to 
'  degeneration  of  the  capsular  epithelium,  for  similar  changes 
are  brought  about  in  Forster's  ripening  of  cataracts  by 
trituration  of  the  lens,  which  trituration  has  been  shown 

*  A.f.  O.,  XXX.  4,  211. 


^/: 


Operable  Cataract  5 

(in  rabbits)  to  result  primarily  in  breaking  down  of  the 
epithelial  cells.  And  in  some  advanced  stages  of  this 
form  of  cataractous  degeneration  ^mplete  disappearance 
of  the  cells  lining  the  capsule  has  been  observe^i. 

The  incipient  stage  of  each  variety  of  cataractous 
change  does  not  concern  us  here.  In  the  typical  unripe 
lens  of  this  class  the  anterior  chamber  is  frequently 
shallowed,  owing  to  swelling  of  the  lens,  and  possibly  also 
to  an  alteration  in  the  shape  of  the  lens.  It  may  become 
more  iTSarl)r~gpherical  by  distension  of  the  capsule  and 
softening  of  the  contents.  The  rounded  apices  of  opaque 
bluish-white  glistening  sectors  of  varied  breadth  are  seen 
within  the  normal  pupil,  separated  by  a  little  clear 
cortex.  Since  the  opacity  affects  the  superficial  fibres  of 
the  lens,  the  iris  throws  no  shadow.  There  are  other 
cases  less  typical,  in  which  the  anterior  chamber  is  less 
often  shallow,  and  the  soft  cortical  matter  is  uniformly 
clouded  and  dull. 

The  ripe  stage  of  this  form  of  cataract  appears  to  be  a 
short  one,  as  it  is  not  very  frequently  seen. 

In  the  overripe  stage  there  is  definite  liquefaction,  at 
first  of  the  superficial  cortex  only,  but  soon  involving  the 
deeper  cortex,  and  eating  away  more  or  less  of  the  nucleus 
also.  Thus  we  get  the  Morgagnian  cataract,  with  nucleus 
floating  free  in  milky  fluid.  The  nucleus  may  be  small, 
transparent,  and  amber- coloured,  or  larger,  dark,  and 
opaque.  The  capsule  is  either  quite  transparent,  or  there 
is  faint  diffuse  opacity  only,  or  this  with  numerous  small 
brilliantly  white  dots.*  The  opacity  may  be  limited  to 
the  anterior  capsule  or  may  extend  more  or  less  over  the 
posterior  portion  also.     The  anterior  chamber  may  still 

*  These  discrete  opaque  points  were  found  exclusively  in  our 
practice  in  Morgagnian  cataracts,  and  in  lenses  which  had  passed 
through  the  Morgagnian  phase.  Occasionally  some  capsular  opacity 
develops  early,  when  the  cataract  is  barely  mature. 


6  Cataract  Extraction 

be  shallow,  and  actual  measurements  taken  in  Bombay 
show  that  /some  Morgagnian  lenses  are  above  the 
normal  in  volume^  But  absorption  of  the  milky  fluid 
tends  to  gradually  progress  until  nothing  remains  but  the 
nucleus  in  the  collapsed  capsule,  /very  rarely  the  nucleus 
disappears  entirely,  in  adults  beyond  middle  age,J  while 
the  sac  is  still  distended  with  fluid.  The  fluid  tnen  has 
a  creamy  tint.  In  India  the  overripe  stage  of  congenital 
or  infantile  cataract  is  not  rarely  seen  in  children  as  a 
thin  layer  of  milky  fluid  in  an  opaque  flattened  sac.  In 
adults  some  of  the  very  overripe  lenses  have  still  quite 
transparent  capsules,  others  opaque.  Some  become 
tremulous,  others  do  not.  Those  without  tremor  are  not 
clinically  recognizable  through  the  undilated  pupil.  The 
capsule  having  retracted  away  from  the  iris,  a  narrow 
space  is  left  through  which  a  shadow  may  be  cast  by  the 
iris.  In  our  practice  the  nature  of  the  cataract  was  some- 
times not  known  till  an  iridectomy  had  been  made  during 
operation,  revealing  a  dark  space  above  the  shrunken 
nucleus. 

Opaquer  capsules  are  not  only  thickened  and  toughenad^  and 
therefore  difficult  to  cut  during  operation,  but  are  also  inelastic. 
The  edges  of  any  opening  made  in  the  membrane  at  the  time 
of  the  cataract  extraction  or  later  tend  to  come  together  again. 

Apart  from  these  shrunken  overripe  lenses  and  from  sub- 
luxated  lenses,  marked  tremor  of  the  lens  may  be  taken  to 
indicate  possibly  both  fluidity  of  vitreous  and  atrophy  of 
zonule.  In  the  cases  now  dealt  with  there  may  be  no  notice- 
able^oftening  of  the  vitreous,  and,  where  liquefaction  is  present, 
the  change  may  be  confined  quite  to  the  anterior  portion  of 
the  humour,  and  may,  perhaps,  be  explained  by  the  repeated 
impact  of  the  shaking  lejj/  Atrophy  of  the  zonule  is  com- 
monly assumed  also,  but  I  do  not  know  upon  what  grounds. 
The  tremor  is  sufficiently  explained  by  the  loose  state  of  the 
almost  empty  and  inelastic  capsule.  I  have  a  strong  impres- 
sion that  in  the  cases  where  only  the  nucleus  remains  in  the 


operable  Cataract  7 

sac,  and  where  yet  the  lens  is  not  tremulous,  the  capsule  is 
always,  or  at  least  generally,  transparent,  and  therefore  pre- 
sumably still  elastic.  (^In  the  overripe  stage  of  the  second 
variety  of  cataract  formation  mentioned  above — the  shrunken 
disc — there  is,  according  to  our  experience,  never  any  tremor/ 
These  lenses  have  not  passed  through  any  swollen  stage,  during 
which  the  elasticity  of  the  capsule  might  have  become  reduced 
by  over-distension. 

11.  Shrinking  Cataracts. — In  most  cataracts  at  a  very 
early  stage,  and  in  many  throughout  their  whole  course, 
there  is  no  evidence  of  an  excess  of  fluid  within  the  lens. 
On  the  contrary,  when  the  degeneration  is  well  advanced, 
the  cortex  is  distinctly  firmer  and  apparently  drier*  than 
normal.  A  slow  progressive  reduction  in  size  takes  place. 
Priestley  Smith  showed  that  in  incipient  cataract  the  lens 
is  commonly  reduced  in  bulk.  In  the  later  stages  the 
shrinkage  is  often  very  striking.  In  patients  of  middle 
age  and  under,  in  whom  nuclear  sclerosis  is  not  very 
advanced,  the  shrinkage  tends  to  be  especially  noticeable 
antero-posteriorly. 

It  may  be  stated  generally  that  this  progressive  loss  of 
substance  and  loss  of  transparency — this  evidence  of 
defective  nutrition  of  the  lens  as  a  whole — may  pass 
through  its  whole  course  uncomplicated ;  but  it  is  liable 
to  be  modified  at  any  stage  by  the  addition  of  changes 
recognizable  as  due  to  the  admission  of  fluid,  indicating 
probably,  as  above  stated,  diminished  resistance  of  the 
subcapsular  cells.  Thus  the  frequent  blending  of  the 
two  types,  rendering  rigid  classification  impossible. 

The  typical  unripe  cataracis^een  through  the  pupil 
have  usually  a  diffused  greenish  appearance,  perhaps 
tinged  with  olive  from  nuclear  sclerosis.  In  a  few  cases 
the  opacity  is  greyish,  but  is  then  quite  deep — nuclear  or 

*  This  may  be  shown  in  the  staining  and  decolouring  of  micro- 
scopical sections. 


8  Cataract  Extraction 

perinuclear.  There  is  a  quantity  of  perfectly  clear  cortex, 
through  which  a  very  distinct  shadow  is  thrown  by  the 
iris.  This  deep  central  uniform  cloudiness  may  remain 
with  but  little  change  for  years,  affecting  vision  greatly 
from  its  position,  but  remaining  quite  unfit  for  operation. 
In  other  eyes  the  (greenish)  opacity  comes  well  up  to  the 
iris,  but  it  is  so  slight  that  a  faint  shadow  is  transmitted 
from  the  iris  through  the  superficial  layers  of  the  lens. 
The  transparent  appearance  of  such  a  lens  after  removal 
is  remarkable ;  there  may  or  may  not  be  a  small  central 
haze  or  cloud  of  opacity  noticeable  (after  removal).  The 
superficial  layers,  though  so  clear,  are  fairly  firm  and 
coherent,  and  shell  out  easily  entire. 

In  the  ripe  stage  these  lenses  vary  considerably  in  size 
and  appearance.  The  diminution  in  size,  especially  in 
thickness,  varies  inversely  with  the  degree  of  nuclear 
sclerosis,  and  therefore  to  a  large  extent  with  the  age  of 
the  patient.  A  broad  thick  disc  may  result,  with  sharp 
edge ;  but  more  frequently  the  contraction  is  lateral  as  well 
as  antero-posterior.  The  nucleus  ranges  from  opaque  white 
or  cream-coloured  in  a  few  rather  young  lenses  with 
defective  sclerosis,  through  the  average  smoky  brown,  to 
the  larger  dark  hypersclerotic  nucleus.  The  lenses  with 
whitish  nucleus  may  appear  perfectly  ripe  clinically, 
while  on  extraction  the  equatorial  rim  of  cortex  may  be 
found  quite  or  nearly  transparent.  This  thin  transparent 
or  translucent  rim  is,  however,  firm,  and  separates  whole 
from  the  capsule.  In  other  lenses  the  distinction  between 
nucleus  and  cortex  is  not  very  evident ;  the  loss  of  trans- 
parency seems  uniform  throughout,  but  very  incomplete. 
There  may  be  fine  superficial  radial  slits  or  cracks  on  the 
anterior  surface. 

The  overripe  lens  is  remarkable  for  its  flattened  discoid 
shape,  and  often  for  its  small  size ;  also  for  the  amount 


Operable  Cataract  9 

of  capsular  thickening  and  opacity  that  develops,  often 
with  a  large  anterior  central  untearable  patch,  possibly 
containing  lime  deposits.  What  remains  of  the  cortex 
consists  chiefly  of  a  broad  equatorial  ring,  cream-coloured 
and  coherent,  but  separating  readily  from  the  nucleus. 
The  latter  varies  in  size  and  colour,  as  in  Morgagnian 
cataracts,  but  it  is  commonly  rather  larger  and  less  clear. 

Its  colour  is  seen  clinically  through  the  scanty  remains 
of  anterior  cortex.  Very  rarely  the  nucleus  may  have 
disappeared,  only  scanty  cheesy  cortex  remaining. 

III.  The  third  variety  of  cataract  formation  is  a  very 
slow  hypersclerosis — pathological  excess  of  the  normal 
nuclear  sclerosis — by  which  almost  the  whole  lens  may 
become  hard,  dark,  and  considerably  opaque.  It  is 
relatively  commop  in  r^yppir  ^y^g  In  pure  hypersclerosis 
the  colour  attained  is  finally  pure  black,  after  passing 
through  a  brownish-red  tint,  which,  however,  appears 
muddy  only  as  seen  through  the  pupil  clinically.  These 
lenses  are  always  large,  but  an  exact  comparison  of  their 
volume  with  the  normal  at  given  ages  yet  remains  to  be 
made.  Since  there  may  be  always  a  trace  of  normal 
cortex  at  the  sarfp-Ce,  capsular  opacity  is  very  rarely 
present.  VisiorK^ommonly  remains  equal  to  the  counting 
of  fingers  at  a  foot  or  more  from  the  eye — at  least,  with 
dilated  pupils — long  after  the  cataract  is  ready  for  ex- 
traction. At  any  stage  of  the  sclerosis  the  unaffected 
cortex  may  undergo  the  ordinary  grey  degeneration, 
resulting  in  one  of  the  mixed  forms  of  cataract. 

In  possibly  half  the  primary  cataracts  seen  in  Bombay 
the  second  form  of  change  persists  alone.  There  is  pro- 
gressive shrinkage  and  opacification.  There  may  be 
abnormal  proliferation  of  lens  cells,  producing  dense 
capsular  opacities,  but  little  or  no  excess  of  fluid  enters 
the   lens.       Taking   the   final    results   only,    Morgagnian 


^y[A/yy-<  CU:  ivuH^    dwu/V^M^ 


li^fU 


lo  Cataract  Extraction 

cataracts  are  much  commoner  than  overripe  cheesy  discs ; 
but  this  represents  the  greater  rapidity,  rather  than 
greater  frequency,  of  the  liquefying  process.  A  very  late 
combination  may  rarely  be  seen  in  an  overripe  cataract, 
partly  fluid,  but  containing  also  a  coherent  equatorial  ring 
of  cortex.  An  earlier  combination  is  sometimes  clearly 
seen  in  fairly  young  patients — well-marked  whitish  nuclear 
opacity,  together  with  ripe,  soft,  flaky  cortex. 

On  rare  occasions  the  two  types  of  degeneration  may  be 
seen  in  the  one  patient — typical  shrinking  cataract  in  one 
eye,  liquefying  in  the  fellow  eye. 

Duration  of  the  Changes. — The  most  rapid  formations 
are  the  swollen  liquefying  ones,  as,  indeed,  one  expects 
from  a  slight  acquaintance  with  traumatic  cataract.  In 
a  month  a  great  change  may  take  place  in  such  lenses. 
To  go  to  the  opposite  end  of  the  scale,  we  have  the  deep 
central  haze  and  hypersclerosis,  both  extremely  slow, 
perhaps  changing  very  little  in  the  course  of  several  years. 
To  formulate  a  rough-and-ready  rule,  one  may  say  :  the 
deeper  the  opacity,  the  slower  it  will  be  ;  the  more  super- 
ficial the  change,  the  faster  it  will  progress. 


COMPLICATED  AND  TRAUMATIC  CATARACTS. 

In  the  it^ipient  cataract  of  advanced  chronic  glaucoma 
a  centraKhaze  is  very  often  the  only  form  of  opacity. 
Cataract  secondary  to  choroidal  and  vitreous  changes  is 
apt  to  remain  long  limited  to  the  posterior  surface.  In- 
cipient cataract,  developing  in  a  highly  myopic  eye,  is 
classed  as  secondary  if  there  be  disease  of  the  vitreous  ;  it 
may  be  of  very  slow  formation.  When  too  advanced  to 
allow  the  fundus  to  be  seen,  a  limitation  of  the  field  of  pro- 
jection would  suggest  detachment  of  the  retina,  especially 
if  the  tension  of  the  eye  were  low,  and  would  contra- 


Operable  Cataract  ii 

indicate  operation.  Traumatic  cataract  uncomplicated 
with  severe  irido-cyclitis  affords  the  purest  type  of  the 
swelling,  liquefying  degeneration.  The  result  differs  from 
that  of  primary  liquefying  cataract,  in  that  more  ready 
means  of  absorption  is  provided  for  broken-down  lens 
substance ;  but  the  soft  plentiful  incoherent  cortex,  and 
the  swelling  of  the  lens  are  the  same  in  both.  It  stands 
in  direct  contrast  with  some  of  the  shrinking  cataracts, 
where  the  opacity  may  be  at  first  entirely  deep,  and  where 
the  evidences  point  to  a  lack  of  moisture  rather  than  to  an 
increase  of  it. 

OPERABILITY. 

The  question  with  which  we  are  immediately  concerned 
is  whether  a  progressive  cataract  is  fit  for  extraction  or 
not.  The  rule  in  the  Cowasjee  Jehangir  Hospital  is  to 
insist  on  threetaefttlfonditions  only,  with  moderate  general 
health. 

I.  The  cataract  must  be  ripe  ejiough.  Complete  maturity 
is  not  required  in  either  of  the  types  of  cataract  for- 
mation. The  shrinking  lenses  with  cortex  firmer  than 
normal  are  often  fit  for  operation  when  the  patient  can 
count  fingers  four  or  five  feet  distant.  Immaturity  entails 
an  iridectomy  as  part  of  the  operation  (a  preliminary 
iridectomy  in  Critchett's  practice),  a  full-sized  incision, 
and  very  slow  expression  of  the  lens.  The  very  shallow 
anterior  chamber  found  with  some  unripe  swollen  lenses 
constitutes  a  difficulty,  but  not  a  serious  one. 

Schweigger  *  and  Hirschberg  f  pointed  out  that  incompletely 
opaque  lenses  could  be  removed  satisfactorily  from  the  eyes  of 
old  people.  Schweigger  found  that  certainly  after  sixty  years 
of  age,  and  possibly  a  little  earlier,  operation  might  be  indi- 
cated while  the  greater  part  of  the  lens  was  still  transparent. 

*  Cbl.f.pr.  ^.,  xiv  (1890),  206.  t  Ibid.,  210. 


12  Cataract  Extraction 

Hirschberg   fixed   the   age   limit   even  lower — at  fifty  years. 
Beyondxoiis  age  the  lens  might  be'  extracted  as  soon  as  the 
opaj^fy  troubled  the  patient  seriously  or  prevented  him  earning 
^"livelihood. 

In  Bombay  we  have  found  that  the  lenses  fit  for  extraction 
could  be  distinguished  by  their  appearance.  /They  include 
many  lenses  with  cortex  only  slightly  opaque  i/but  the  opacity, 
such  as  it  is,  is  quite  recognizable  in  the  mo^lfsuperficial  layers, 
and  is  greenish  ij>  tint.  These  lenses  have  to  be  distmguished 
from  others  unfit  for  operation,  though  the  opacity  is  more 
obvious  and  affects  the  superficial  layers.  In  these  cases  the 
opacity  is  greyish  in  tint,  and  some  slight  swelling  of  the  lens 
may  be  shown  by  an  anterior  chamber  a  little  shallower  than 
that  of  the  fellow  eye.  rt^his  greyish  cortex  is  soft  and  sticky, 
and  does  not  separate  readily  from  the  capsule^  One  must 
expect  trouble  with  cortex  also  should  one  operate  upon  a 
swollen  lens  with  glistening  opaque  sectors,  while  still  trans- 
parent superficial  cortex  is  to  be  seen  in  the  pupillary  area 
between  the  apices  of  the  sectors. 

2.  The  pupil  should  react  well  to  light.  This  is  accepted 
as  a  nearly  certain  guarantee  that  the  fundus  is  sufficiently 
sound  to  justify  operation.  Should  the  movement  of  the 
pupil  be  impaired,  the  tension  of  the  eye  and  the  projec- 
tion of  light  in  the  dark  room  are  tested.  When  sluggish- 
ness is  due  to  glaucoma  or  optic  atrophy  or  other  fundus 
affection,  each  case  must  be  judged  on  the  available  data. 
The  field  of  projection  is  the  main  criterion,  but  it  is  often 
an  insufficient  one.  More  particularly  where  the  other 
eye  is  lost  or  useless,  one  must  operate  if  there  is  any 
reasonable  prospect  of  obtaining  vision  beyond  the  mere 
perception  of  moving  bodies,  the  patient  being  told  before- 
hand of  the  uncertainty  of  the  result. 

Very  occasionally  a  disappointing  result  is  obtained,  in  spite 
of  a  previously  active  pupil.  In  highly  myopic  eyes  testing 
the  field  of  projection  may  afford  evidence  of  detachment  of 
the  retina.  /^  Central  choroidal  atrophy  is  a  not  very  infrequent 
source  of  disappointments  If  considered  desirable,  the  function 


UiI-<UaA,. 


Operable  Cataract  13 

of  the  macular  region  might  be  shown  in  advance  by  testing 
the  patient's  abiHty  to  distinguish  two  ^mall  flames  placed 
close  together  in  the  dark  room. 

3.  There  must  be  no  inflammation  about  the  eye,  and  no 
iritis  or  irido-cyclitis  of  the  fellow  eye.  If  the  other  eye 
be  atrophic  and  tender  from  past  destructive  irido-cyclitis 
following  perforation  of  the  globe,  it  must  be  excised. 
There  must  be  no  trace  of  scleritis,  kexatitis,i4tc.,  nor  any 
scabby  skin  eruption  close  to  the  eye.  The'  conjunctiva 
and  lacrymal  passages  require  particular  attention. 

It  may  be  broadly  stated  that  conjunctivitis  must  be 
treated  until  there  is  no  discharge,  or,  if  this  be  not  quite 
feasible,  special  precautions  must  be  taken  at  the  time  of 
operation. 


In  Ipdia  the  average  condition  of  the  conjunctiva  is  much 
worse  than  in  Europe  and  America.  Various  grades  of  the 
changes  produced  by  chronic  conjunctivitis  are  very  common, 
trachomatous  and  otherwise.  Very  poor  patients  coming  from 
a  distance  must  be  admitted  at  once  or  not  at  all,  and  beds 
cannot  be  spared  for  preliminary  treatment.  Thus  there  are 
constant  demands  for  operation  in  the  presence  of  more  or  less 
chronic  inflammation.  Experience  has  shown  that,  provided 
the  secretion  is  only  scanty  and  mucoid^  scarfielv  any  changes 
in  the  palpebral  conjunctiva  ne^^|0^]^3elay  in  operating. 
We  disregard  papillary  roughness,  thickening,  scarring,  minute 
cysts,  small  follicles  in  the  fornices,  and  scanty  remains  of 
confluent  pale,  lymphoid,  trachomatous  tissue.  Occasionally, 
also,  we  venture  to  admit  patients  with  rather  freer  mucoid 
discharge  and  rather  marked  congestion  of  the  conjunctiva. 
This  is  done,  relying  upon  the  protection  which  we  have  found 
to  be  afforded  by  very  free  perchloride  irrigation  of  the 
conjunctiva  before  operation. 

In  European  practice,  on  the  other  hand,  the  large  majority 
of  the  patients'  conjunctivae  are  of  practically  normal  appear- 
ance, and  operation  can  almost  always  be  postponed  till  the 
surgeon  is  satisfied  with  the  condition.  It  is  usual  before 
operation   to  cleanse  the  conjunctival  surface — the   '  field   of 


^ 


14  Cataract  ExtraQtion 


M'/!^ 


Nil? 


I 


operation ' — merely  mechanically.  Or  if  perchloride  or  cyanide 
of  mercury  or  other  antiseptic  lotion  is  utilized,  it  is  in  no 
measured  and  calculated  systematic  manner,  aiming  at  a 
definite  recognizable  result.  And  it  is  understood  that  no  great 
reliance  can  be  placed  upon  either  the  mechanical  or  the 
chemical  attempts  to  clear,  away  organisms  from  the  field. 
The  treatment  of  any  conjunctivitis  present  must  therefore  be 
very  thorough  before  an  eye  can  be  accepted  as  ready  for 
operation. 

For  rapidly  reducing  the  discharge  from  the  rough  and 
thickened  conjunctivae  with  which  we  had  to  deal  in  India,  we 
found  nothing  equal  to  a  daily-Xather  free  douching  with  sttpng 
perchloride  lotion'  (i  in  3,000).  This  treatment  would  be  too 
severe  for  conjunctivae  of  nearly  normal  appearance. 

I  once  had/4o  delay  operation  for  the  treatment  of  a  con- 
unctival  pouch,  not  caring  to  operate  with  such  an  area  shut 
off  from  the  action  of  the  perchloride  lotion. 

The  Lacrymal  Passages. — Though  cataract  has  been  success- 
fully extracted  numbers  of  times  in  the  presence  of  chronic 
lacyrmal  disease,  the  risk  of  infection  is  so  great  that  opera- 
tion must  be  considered  inadmissible  whenever  there  is  the 
slightest  trace  of  discharge  obtainable  from  the  tear-sac.  No 
patient  should  be  admitted  without  pressure  being  made  over 
the  sac,  while  the  puncta  are  exposed  by  separation  of  the 
eyelids.  This,  however,  in  itself  is  not  a  sufficient  test,  but  it 
is  possibly  enough  if  a  '  test  dressing'  is  always  applied  after  the 
patient's  admission.  This  was  all  that  we  relied  upon  in 
Bombay.  On  a  few  occasions  we  have  been  saved  from 
operating  in  the  presence  of  unsuspected  lacrymal  disease  by 
noticing  a  trace  of  discharge  and  moisture  on  the  lid  borders, 
and  on  the  lint  used,  after  a  night's  application  ofJmie  dressing. 
By  syringeing  then  some  discharge  was  washdd^ut  through  a 
canaliculus.  It  is  doubtless^afer  to  instil  fluorescein,  and  to 
make  the  patient  sit  for  threettr-fr^  minutes  wuth  head  bent 
forward.  If  the  nose  be  then  'blown,'  the  colour  should  be 
seen  on  the  handkerchief.  If  none  is  seen,  the  lacrymal 
syringe  must  be  used. 

Some  surgeons  invariably  wash  out  the  sac  as  a  test  for  dis- 
charge and  for  obstruction  of  the  nasal  duct.  Haab  receives 
the  fluid  which  flows  from  the  nasal  aperture  in  a  black~VBssel 
to  show  turpidity.     Extirpation  of  the  sac  is  to  be  strongly 


Operable  Cataract  15 

urged  in  all  cases  of  dacryocystitis.  After  the  extirpation  the 
eye  should  be  ready  for  operation  in  three  weeks  or  less.  If 
this  radical  treatment  cannot  be  carried  out,  and~Tf  the  dis- 
charge be  scanty,  and  especially  if  it  can  be  forced  down  into 
the  nose  by  .pressure  on^he  sac,  the  puncta  may  be  sealed  with 
the  galvan*^autery.  ^aab,*  using  a  fine  point  and  a  current 
strong  enough  to  bring  it  only  to  a  faint  red  heat,  succeeds  in 
closing  2  or  3  millimetres  of  the  two  canaliculi  temporarily 
only,  y  The  canaliculi  can  be  subsequently  reopened  by  a 
conical  probe.  Or  the  canaliculi  may  be  (perhaps  preferably) 
rendered  temporarily  impervious  by.  ligature  with  catgut  or 
silk,  as  practised  by  Eversbusch,  Buller,  and  Quackenboss. 
Should  either  canaliculus  have  been  freely  slit  open,  these  safe- 
guards are  not  readily  applicable.  Treatment  by  probing  and 
syringeing  may  have  to  be  very  prolonged  before  safety  is 
assured. 

Some  operators  have  found  that  preliminary  opening  of  the 
sac  through  the  skin  and  packing  with  iodoform  or  iodoform 
gauze  for  some  days,  also  filling  the  canthus  with  sterile  iodo- 
form after  operation,  is  sufficient  to  preserve  the  wound  from 
contamination.  Doubtless  considerable  protection  is  afforded 
also  by  the  subconjunctival  methods  of  operating. 

Angelucci  has  practised  division  of  the  canaliculi  with  a 
knife,  cutting  through  the  whole  thickness  of  the  lids,  and 
sealing  the  openings  by  a  touch  with  the  galvano-cautery. 
Later  he  reopens  the  canaliculi  beyond  the  occlusion. 

In  Bombay  we  ignored  nasal  obstruction  from  polypi  and 
thickening  of  mucous  membrane.  In  cases  of  ozaena  the  nose 
was  simply  syringed  out  on  admission,  and  again  shortly  before 
operation  ;  but  cases  with  purulent  discharge  from  the  nose 
were  referred  for  treatment.  Some  surgeons  pay  much  more 
attention  to  the  condition  of  the  nose  and  pharynx ;  but  it  is 
accepted  that  infection  of  the  conjunctiva  from  the  nose  byway 
of  the  lacrymal  passages  does  not  take  place. 

As  regards  corneal  opacity,  it  may  be  stated  that  if  the 
cornea  be  transparent  enough  in  whole  or  in  part  to  admit  of 
the  state  of  the  lens  and  of  the  pupil  being  made  out,  the 
patient  should  see  sufficiently  well  afterwards  to  justify  opera- 
tion. A  pterygium,  if  large,  may  require  removal,  but  if  small, 
may  be  left. 

*  '  Operative  Ophthalmology,'  p.  58. 


liV: 


Cataract  Extraction        i 

The  state  of  the  fellow  eye  may  need  a  small  precautionary 
attention.  If  the  anterior  chamber  be  very  shallow,  it  will  be 
wise  to  in^il  eseriiL  lest  an  attack  of  glaucoma  be  brought  on 
by  the  excitement  and  general  conditions  appertaining  to  the 
operation.     We.  had  experience  of  a  few  such  cases^. 

Very  rarely  a  cataract  may  be  ripe  for  extraction,  and  yet 
the  operation  may  be  impossible.  I  once  had  to  depress  the 
lens  in  each  eye  of  a  patient  with  extremely  small  corneas — 3. 
•congenital  defect  associated  with  coloboma  of  the  iris. 

When  one  eye  has  been  lost  from  profuse  intra-ocular 
haemorrhage  complicating  cataract  extraction,  it  is  a  question 
whether  reclination  should  not  be  preferred  in  the  second  eye 
(see  Chapter  III). 

The  possession  of  good  sight  in  one  eye  influences  the 
question  of  operation  on  the  other  eye,  only  in  so  far  that  it 
germits  of  waiting  for  complete  ripeness  of  the  cataract  without 
iVserious  inconvenience.  The  cataract  mu^t  not  be  allowed  to 
become  hypermature,  because  it  is  then  in  a  less  favourable 
state  for  operation.  After  the  extraction,  although  both  eyes 
^  -  tdo  not  work  together,  there  is  the  advantage  of  the  larger  field 
I  */y  of  vision,  and  the  patient  has  the  satisfaction  of  being  provided 
for  during  the  anticipated  slow  onset  and  progress  of  opacity 
in  the  fellow  eye.  /fi^has  been  argued*  that  until  our  methods 
improve  so  that  we  can  guarantee  the  fellow  eye  against  loss 
by  sympathetic  ophthalmia,  we  have  no  right  to  operate  while 
the  fellow  eye  has  useful  vision.) The  improved  results  obtained 
nowadays  by  a  number  of  operators  show  that  it  should  be 
quite  possible  to  guard  against  sympathetic  ophthalmia,  especi- 
ally where  patients  can  be  kept  under  observation  and  treat- 
ment for  a  sufficient  length  of  time  after  operation.  In  India, 
if  we  did  not  operate  upon  all  cataracts  ready  for  extraction, 
we  should  drive  many  patients  into  the  hands  of  the  travelling 
quacks. 

It  is  almost  universally  held  to  be  unjustifiable  to  extract 
cataracts  from  both  eyes  of  a  patient  at  the  same  time.  The 
possible  loss  of  both  eyes  is  too  appalling  a  risk  to  run,  and 
the  danger  from  mental  derangement,  coughing,  sneezing,  etc., 
is  more  serious.  Operation  upon  one  eye  may  show  the  need 
of  special  precautions  in  dealing  with  the  second  eye.    Finally, 

^^  See,  for  example,  Devereux  Marshall  in  The  Ophthalmoscope,  iv 
(1906). 


\ 


Operable  Cataract  17 

one  eye  alone  may  after  operation  stand  in  need  of  atropin 
instillation  to  the  full  extent  that  the  patient  can  bear  con- 
stitutionally. The  double45peration  is,  however,  still  performed 
occasionpily  under  the  peculiar  conditions  of  district  work  in 
Indiafr  Hansell*  considers  it  justifiable,  and  even  desirable, 
under  certam  circumstances. 

As  regards  the  general  health,  very  little  is  exacted. 
We  never  refused  operation  on  account  of  diabetes.  A 
little  preliminary  treatment  and  regulation  of  diet  appears 
advisable.  We  operated — always  with  good  result — upon 
many  patients  with  albuminuria,  even  with  moderate 
oedema. f  But  we  feared  cases  with  anaemia  and  con- 
siderable oedema.  We  refused  cases,  also,  of  simple 
extreme  anaemia.  'Asthma,  emphysema,  and  chronic 
bronchitis  are  not  contra-indications,  though  they  pre- 
dispose to  prolapse  of  iris,t  and  more  definitely  in  my 
experience  to  slight  iritis  and  to  haemorrhage  into  the 
anterior  chamber.  '  Alleviation  of  dyspnoea  and  cough  is, 
of  course,  desirable,  and  the  patient  cannot  be  kept 
recumbent  after  operation.  Snellen  treats  a  liability  to 
'  constant  sneezing  by  placing  wool  soaked  in  cocain 
solution  within  the  nares.  Extreme  age  of  the  patient 
is  no  bar  to  operation,  though  it  imposes  the  need  for 
particular  care  afterwards.  The  same  may  be  said  of 
insanity  and  of  moderate  degrees  of  epilepsy.  Leprosy, 
also,  is  not  a  contra-indication.  Absolute  deafness  is  a 
minor  trouble.  Suppurating  processes,  ulcers,  etc.,  should 
be  cured,  or  at  least  got  into  a  satisfactory  condition,  if 

*  Ophthalmic  Record,  December,  1903. 

f  We  were  care'ful  always  to  restrict  traumatism  by  operating  with 
gentleness  and  rapidity,  fearing  iritis ;  and  we  sometimes  operated  sub- 
conjunctivally,  feeling  that  the  tissues  of  these  eyes  could  offer  little 
resistance  to  microbic  invasion.  (iTeutschmann  saw  two  suppurations 
in  seven  extractions  in  albuminurias. )  The  prognosis  must  be  guarded 
also,  on  account  of  possible  fundus  lesions  present. 

X  Iridectomy  hence  imperative  in  these  cases. 

"^^^^  2 


1 8  Cataract  Extraction 

only  on  account  of  the  bare  possibility  of  a  pyasmic  con- 
dition setting  in  and  causing  metastatic  inflammation  in 
the  temporarily  weakened  tissues  of  the  eyeball. 

Operation  must  be  deferred  if  there  is  fever,  of  whatever 
origin,  or  recent  syphilis ;  also  on  account  of  menstruation 
or  advanced  pregnancy. 

Age  of  Patients. — A  few  lines  must  be  added  regarding 
the  age  of  the  patient  at  which  extraction  becomes  admissible. 
'  Linear  extraction,'  in  which  the  lens  is  coaxed  out  piecemeal 
through  a  sg?all  incision  made  with  a  keratome,  is  commonly 
preferred    whenever    practicable,   to    the   ordinary   '  flap   ex- 
traction,' in  which  the  lens  is  expressed  whole  or  nearly  whole. 
^      The  former  method  is  applicable  regularly  up  to  thirty  years  of 
"jT      ''^■ge,  and  frequently  somewhat  later,  since  the  absence  of  a 
'VV'^    //hard  nucleus  is  practically  assured  up  to  this  age.     But  in 
Bombay   we   found    that    nearly   all    patients    over    twenty 
years  of  age  had  sufficient  self-control  to  justify  ordinary  extrac- 
tion through  a  shallow  flap  section.     The  removal  of  the  lens 
in  bulk  is  commonly  more  complete,  and  is  accomplished  with 
less   instrumentation   and   manipulation    than   by   the   linear 
method. 

At  an  earher  age  the  length  of  the  inclusion  isi_-Leduced  as 
much  as  possibleTNan  account  of  the  want  of  self-control 
displayed  by  the  patients  both  during  and  after  operation,  and 
possibly  also  on  account'^  more  freo^ient  vitteQJJLS.  ^^"^'""- 
Operation  is  mostly  required  upon  lenses  partly  or  completely 
transparent — for  lamellar  cataract,  or  in  the  treatment  of  high 
myopia.  Linear  extraction  is  preceded  by  one  or  more 
'  needlings,'  by  which  the  lens  substance  is  rendere3~cataractous 
and  loosened  from  its  connexion  with  the  capsule.  The  . 
extractron  may  be  voluntary,  as  an  expeditious  alternative  tci/ 
slow  absorption,  or  it  may  be  demanded  by  the  onset  of  plus 
tension  or  inflammatory  reaction,  excited  by  the  swollen  and 
disintegrating  lens.  Some  surgeons  prefer  primary  incomplete 
extraction  of  the  transparent  lens,  holding  that  the  duration  of 
treatment  is  shortened,  and  that  the  reaction  from  retained 
lens  matter  is  likely  to  be  less  than  that  frequently  experienced 
when  the  extraction  is  preceded  by  needling. 

In  young  thildren  absorption  by  repeated  needlings  is  aimed 


Operable  Cataract  19 

at,  linear  extraction,  or  rarely  removal  by  suction,  being  under- 
taken as  a  rule  only  under  compulsion  from  complications 
arising.  'lli'" 

Cataracts  treated  in  'mfants  are  usually  complete.  The 
opacity  must  be  removed  as  early  as  possible,  to  enable  the 
functions  of  the  retina  and  of  the  visual  nervous  mechanism  to 
develop.  At  this  age  the  shallow  anterior  chamber,  and  a 
difficulty  in  keeping  ihe  pupil  dilated  with  the  weak*  atropin 
instillations  admissib^,  are  obstacles  in  the  way  of  treatment 
by  repeated  needlings  ;  yet  this  treatment  should  be  persisted 
in,  if  possible.  I  have  practised  linear  extraction  under  the 
age  of  one  year,  but  in  one  case  at  least  I  regretted  it.  Ex- 
traction was  performed  in  both  eyes  without  preliminary 
needling.  The  cataracts  were  rather  firm  and  wax-like,  but 
were  removed  piecemeal  with  the  aid  of  irrigation.  The  small 
incisions  were  subconjunctival,  yet  both  eyes  were  reported  to 
have  suffered  from  persistent  low  inflammatory  changes  after- 
wards. There  was  an  interval  of  some  weeks  between  the  two 
operations,  and  both  eyes  did  well  while  under  observation. 
The  patient  had  been  brought  from  a  distance,  and  the  relations 
were  unwilling  to  stay  for  prolonged  treatment  by  needlings. 
Extraction  has  been  considered  necessary*  for  this  form  of 
cataract,  but  discissions  should  suffice. 


THE  ARTIFICIAL  RIPENING  OF  CATARACT. 

Up  to  thirty  or  thirty -five  years  of  age  discission  is  the 
method  adopted  for  rendering  transparent  lens  matter  opaque. 
To  be  safe  and  sure,  'ripening,'  by  the  admission  of  aqueous 
through  an  opening  in  the  capsule,  must  be  slow  and  gradual. 
The  primary  needling  must  be  limited,  lest  by  rapid  swelling 
and  disintegration  of  the  lens  high  tension  and  irritation  of  the 
iris  be  excited.  Extraction  may  then  have  to  be  undertaken 
with  the  posterior  layers  of  the  lens  still  transparent  and 
adherent  to  the  capsule,  and  with  the  eye  congested  and 
irritable.  The  extraction  is  incomplete,  and  more  or  less  iritis 
'  frequently  follows.  But  slow  ripening  by  repeated  needlings 
is  very  satisfactory  in  young  subjects.  (Stellwag,  in  1886,  tried 
discission  of  the  posterior  capsule.)     Beyond  the  above-men- 

*  See  Czermak,  *  Die  Augenarztlichen  Operationen,'  p.  1094. 

2 — 2 


20  Cataract  Extraction 

tioned  age  experience  has  shown  that  the  eye  too  frequently 
resents  the  needling  of  transparent  lens  matter. 

It  is  between  the  ages  of  forty  and  sixty  that  the  question  of 
the  ripening  of  progressive  cataracts  generally  arises.  Many 
surgeons  apparently  fix  no  age  limit  in  their  extractions  of  un- 
ripe senile  cataract ;  but  others  prefer  Forster's  ripening  by 
trituration  of  the  lens  under  sixty  years  of  age.  An  iridec- 
tomy is  performed,  and  the  lens  massaged  by  spoon  pressure 
through  the  cornea.  The  ripening  takes  from  oneNw-^ght 
weeks,  according  to  the  condition  of  the  lens  and  the  dura- 
tion of  the  massage.  Sometimes  the  treatment  has  proved 
insufficient,  and  various  complications  have  been  met  with — 
iritis,  rupture  of  the  zonule,  or  rarely  of  the  capsule,  and  very 
rarely  abscess  of  the  cornea.  But  they  all  appear  to  be  avoid- 
able by  correct  procedure.  Individual  operators  have  been 
able  to  report  some  hundreds  of  successful  cases  free  from 
complication.  The  method  is  held  to  be  contra-indicated  by 
advanced  atheroma  (lest  glaucoma  be  induced),  and  by 
choroiditis  or  fluid  vitreous,  and  in  some  marasmatic 
patients. 

'  Preliminary  iridectomy  alone  has  proved  effectual  occasion- 
ally, but  it  cannot  be  depended  upon.  Massage  through  the 
cornea  after  simple' paracentesis  has  been  fairly  satisfactory. 
It  has  been  combined  with  puncture  of  the  lens  capsule.* 
Direct  massage  of  the  lens  with  a  small  spatula  after  para- 
centesis has  been  preferred  by  Ricaldi,  Bettmann,  and  others, 
to  Forster's  method. 

McKeown's  and  Jocq's  attempts  to  ripen  by  injecting  fluid 
within  the  capsule  appear  to  have  worked  mainly  as  simple 
discissions. 

Wolff  berg  f  has  ripened  cataracts  with  a  hot-air  douche, 
directed  upon  the  closed  lids  by  means  of  a  '  kalorisator.' 
With  two  or  three  applications  a  day  maturation  was  accom- 
plished in  about  a  week.  Maynard  J  thinks  extraction  in  the 
capsule,  as  practised  by  Smith,  often  a  very  effective  means  of 
dealing  with  unripe  cataract.  ) 

*  Fage,  Ann.  cTOcuL,  cxxix. 

t    Woch.  f.    Ther.   u.   Hygiene  des    Atif^es,   September    22    and 
October  6,  1904. 
X  '  Manual  of  Ophthalmic  Operations,'  Calcutta,  1908,  p.  55. 


operable  Cataract  21 


THE  VOLUME  OF  CATARACTOUS  LENSES. 

Some  years  ago  I  measured  a  few  lenses  in  their  capsules  in  a 
Priestley  Smith's  lens  measurer,  immediately  after  extraction. 
The  point  brought  out  was  that  some  of  the  cataractous  lenses 
of  the  liquefying  type,  either  Morgagnian  or  less  advanced, 
were  distinctly  swollen  beyond  the  extreme  normal  limits  by 
the  imbibition  of  aqueous.  It  is  unnecessary  to  demonstrate 
by  measurement  the  reduction  in  size  which  is  seen  in  many 
shrinking  cataracts.  The  measurements  are  given  in  tabular 
form,  together  with  the  extreme  limit  and  the  average  bulk  of 
the  normal  lens  at  the  same  age,  as  computed  roughly  from 
Priestley  Smith's  table.*  But  it  is  to  be  noted  that  the  average 
normalrefis  of  the  native'^r  Bombay  is  probably  appreciably 
smaller  than  that  taken  from  Priestley  Smith's  measurements 
in  England,  in  correspondence  with  the  poorer ^veragephysique 
in  Bombay.    ;;  '       ;  T         i„         ■ 

*  Reproduced  in  Norris  and  Oliver's  '  System,'  iv.  286. 


22 


Cataract  Extraction 


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CHAPTER  II 
DESCRIPTION  OF  THE  OPERATION 

Historical  outline — Instruments — General  arrangements  —  Prepara- 
tion of  the  patient- — Preliminaries — Initial  steps — The  combined 
operation — The  section — The  iridectomy — The  opening  of  the 
capsule — The  delivery  of  the  lens  —  Toilet  of  the  eye — The 
dressing — After-course  and  after-treatment. 

ROUGH  GENERAL  HISTORICAL  OUTLINE  OF 

THE  DEVELOPMENT  AND  PROGRESS  OF 

CATARACT  EXTRACTION. 

Though  lenses  dislocated  into  the  anterior  chamber  had  been 
removed  early  in  the  eighteenth  century  by  St.  Yves  and  P.  du 
Petit,  it  was  not  till  17 "^2  that  Daviel  published  his  method  of 
extracting  cataractous  lenses  from  behind  the  iris,  already 
tested  in  over  200  operations. 

Holding  the  lower  lid  depressed,  he  punctured  with  a  broad 
needle  at  the  lower  corneal  margin,  and  enlarged  the  opening 
at  either  side — first  with  a  blunt-pointed  needle,  and  further 


Fig.  I. — Beer's  Knife. 

with  curved  scissors.  Thus  almost  a  semicircular  flap  was 
outlined.  The  anterior  capsule  was  then  simply  opened  with 
a  fine  lancet,  or,  if  thickened,  incised  circularly  and  partly 
removed  with  forceps.  The  lens,  after  being  loosened  in  its 
bed  by  the  insertion  of  a  narrow  spoon  between  lens  and  iris, 
was  delivered  by  pressure  on  the  globe  below,  applied  by  the 
index  and  middle  fingers  through  the  lower  lid. 

The  manner  of  cutting  the  section  was  soon  improved  by 
the  introduction  of  the  broad  triangular  knives  of  Beranger, 
Beer,  and  others.     With  these  a  semicircular  incision,  placed 

23 


24  Cataract  Extraction 

in  clear  cornea  a  little  within  the  limbus,  was  completed  in  a 
single  short  thrust. 

The  fairly  frequent  suppuration  of  the  cornea  met  with  was 
attributed  then  to  the  tendency  of  the  flap  section  to  gape, 
preventing  early  union.  Hence  followed  attempts  to  extend 
the  application  of  what  became  known  as  '  simple  linear 
extraction,'  originally  employed  only  for  luxated  lenses.  The 
slightly  curved  wound,  made  with  a  lance-shaped  knife  or 
keratome,  was  made  as  large  as  possible,  and  by  von  Graefe  was 
placed  near  the  upper  margin  of  the  cornea  and  combined  with 
an  iridectomy.  But  even  so,  it  was  found  to  admit  of  the  easy 
exit  only  of  capsular,  shrunken,  and  soft  cataracts,  and  of  lenses 
with  small  nuclei  and  plentiful  soft  cortex,  readily  broken  up. 

Critchett  and  Bowman  (1864)  increased  the  size  of  the 
wound,  making  a  very  shallow  corneal  flap  section,  but  found 
it  necessary  to  draw  out  the  lens  with  the  scoops  which  still 
bear  their  names. 

Jacobson  lessened  the  number  of  suppurations  by  the  applica- 
tion of  another  principle.     He   returned   to  the  lower  semi- 

/ 


Fig.  2. — Jacobson's  Incision. 

circular  flap,  but  placed  it  further  back  behind  the  visible 
corneal  margin,  so  that  it  lay  partly  in  the  sclerotic.  He 
recognized  that  the  vascular  scleral  tissue  was  less  disposed  to 
I  suppuration  than  the  non-vascular  cornea.  The  large  size  and 
peripheral  position  of  the  wound  necessitated  an  iridectomy  to 
guard  against  the  tendency  to  prolapse  of  iris. 

Von  Graefe  in  1865  attempted  to  combine  both  safeguards 
against  suppuration — a  linear  wound  and  scleral  position. 

The  so-called  linear  extraction  by  incision  with  a  keratome 


Fig.  3. — Jaeger's  Keratome. 

(*  Lanzenextraction ')  is  not  by  a  truly  linear  incision.      The 
latter  must  lie  in  a  plane  perpendicular  to  the  surface,  in  a 


Description  of  the  Operation  25 

corneal  meridian,  and  such  a  section  is  obviously  impossible 
with  a  keratome  if  made  of  any  length. 

In  order  to  ensure  the  closest  possible  contact  of  the  wound  sur- 
faces, von  Graefe  designed  an  incision  approximating  as  closely 
as  practicable  to  an  arc  of  the  largest  possible  circle,  being, 
therefore,  in  line  and  plane  as  nearly  as  possible  in  a  radius  of 
the  scleral  curve.  The  lance  knife  had  to  be  replaced  by  a 
narrow-bladed  instrument  for  the  new  incision,  at  a  consider- 
able angle  to  the  iris.  Hence  the  Graefe's  knife,  suited  for 
transfixion  by  puncture  and  counter-puncture,  which  has  long 
survived  the  operation  which  made  its  value  generally  known. 
With  this  knife  a  section  was  made  with  its  centre  close  to  the 
upper  corneal  margin,  but  its  ends  some  little  distance  away  in 
the  sclerotic.     In  von  Graefe's  original  incision  the  points  of 


Fig.  4. — Von  Graefe's  Incision. 

entry  and  emergence  of  ihe  knife  were  situated  a  little  over 
I  millimetre  from  the  cornea,  and  i'5  millimetres  below  a 
tangent  drawn  through  the  summit  of  the  corneal  circum- 
ference. The  plane  of  the  section  at  its  two  ends  was  parallel 
to  the  iris  surface,  but  for  the  rest  of  its  extent  nearly  perpen- 
dicular to  the  surface  of  the  globe.  The  knife  edge  had  to  be 
turned  sharply  forwards  as  soon  as  the  globe  was  transfixed. 
This  incision  proving  too  short,  it  was  slightly  elongated  and 
its  curve  increased,  by  lowering  its  ends.  Its  plane  was  thereby 
also  a  little  altered,  being  directed  more  obliquely  to  the  surface. 
In  making  the  puncture  the  knife  was  always  directed  towards 
the  centre  of  the  pupil,  to  make  the  deep  wound  as  large  as 
possible.  The  position  of  the  section  necessitated  the  cutting 
of  a  short  conjunctival  flap.  A  large  iridectomy  was  always 
made,  and  on  this  account  the  operation  known  as  the 
'  peripheral  linear,'  was  also  known  as  the  '  modified  linear ' 
extraction,  to  distinguish  it  from  the  *  simple  '  operation  with- 
out iridectomy.  The  method  had  a  great  vogue  for  a  number 
of  years,  largely  replacing  the  old  flap  extraction. 

Though  suppuration  of  the  wound  and  panophthalmitis  were 


26  Cataract  Extraction 

largely  eliminated  by  this  new  method  of  operating,  this 
advantage  was  counterbalanced  by  an  increase  in  the  number 
of  deep  infective  inflammations  and  of  sympathetic  disease  of 
the  fellow  eye.  And  there  were  smaller  drawbacks.  Greater 
skill  was  required  than  for  the  flap  section,  and  there  was  often 
trouble  from  haemorrhage  into  the  anterior  chamber.  The 
delivery  of  the  lens  through  the  narrow  wound  was  often 
difficult.  Owing  to  this  and  to  the  peripheral  situation  of  the 
wound,  loss  of  vitreous  was  not  infrequent,  and  cystoid  scars 
developed  from  inclusion  of  iris  in  the  angles  of  the  wound. 

Weber*  attempted  to  avoid  gaping  of  the  section,  both  such 
as  is  liable  to  occur  in  linear  wounds  by  retraction  of  the  wound 
surfaces,  and  also  that  by  forward  displacement  of  a  corneal 
flap.  He  endeavoured  to  make  an  almost  linear  incision  large 
enough  for  the  delivery  of  hard  cataracts  complete,  in  a  plane 


F'lG.  5. — Weber's  Knife. 

parallel  to  the  iris,  by  means  of  a  heart-shaped  keratome 
curved  with  the  concavity  backwards.  But  the  section, 
10  millimetres  long,  was  not  sufficient  for  lenses  with  large 
nuclei.  The  instrument,  perhaps,  requires  notice  rather 
than  the  method.  Used  even  earlier  by  Santarelli  (in  1795) 
and  by  Jaeger  (in  1866),  it  is  again  employed  at  the  present  day 
by  Sattler  for  extraction  of  the  transparent  lens  in  high  myopia. 

The  feeling  that  Graefe's  incision  was  too  peripheral  led  to 
alterations  in  two  directions.  Many  operators  preserved  the 
scleral  site,  but  made  the  section  more  arched  by  lowering  the 
ends  of  incision  and  bringing  them  closer  to  the  cornea. 
Others  preserved  the  linear  character  of  the  wound  very  largely, 
but,  relying  on  antiseptic  measures,  displaced  the  section  well 
into  the  cornea. 

Von  Arlt  and  his  pupils — Becker,  Fuchs,  and  others — 
for  long  practised  a  section  scarcely  at  all  modified  from 
von  Graefe's.  The  puncture  and  counter-puncture  were  2  milli- 
metres below  the  tangent  of  the  upper  margin  of  the  cornea, 

*  A.f.  a,  xiii  (1867). 


Description  of  the  Operation  27 

and  lay  in  the  tangents  of  the  outer  and  inner  margins,  and 
were  i"5  milHmetres  from  the  cornea.  The  centre  of  the 
section  was  placed  either  a  little  above,  or  in,  or  a  little  below 
the  corneal  margin. 

Horner  and  many  others  lowered  the  ends  of  the  section 


Fig.  6. — Von  Arlt's  Fig.  7. — Horner's 

Incision.  Incision. 

further,  and  thus  the  linear  section  became  changed  into  a 
shallow  peripheral  flap  section. 

Liebreich's  corneal  section  (1872)  was  much  practised  in 
England.  It  was  made  by  preference  downwards,  and  without 
iridectomy.  The  whole  incision,  including  puncture  and 
counter-puncture,  was  made  with  a  very  narrow  Graefe's  knife, 
inclined  downwards  and  forwards  at  an  angle  of  45  degrees.  The 
extremities  of  the  wound  lay  in  the  sclerotic,  i  millimetre  from 
the  cornea  and  2  millimetres  below  the  horizontal  corneal 
meridian.  The  middle  of  the  incision  fell  i*5  to  2  millimetres 
within  the  corneal  circumference. 

Lebrun  (1872)  made  a  shallow  flap  section  upwards,  purely 
corneal.    The  ends  of  the  incision  were  i  to  2  millimetres  below 


Fig.  8. — Liebreich's  Fig.  9.— Lebrun's 

Incision.  Incision. 

the  horizontal  corneal  meridian;  the  summit  of  the  arch  was  at 
about  the  upper  border  of  the  undilated  pupil.  It  was  made 
with  the  narrow  blade  at  an  angle  of  about  30  degrees  with  the 
surface  of  the  iris. 

(What  is  known  as  Kuchler's  section,  forming  a  straight, 
horizontal  line  across  the  centre  of  the  cornea,  may  be  men- 
tioned here  as  having  been  actually  practised  about  this  time.) 

The  flap  section  again  came  gradually  into  fashion,  but  for  the 


28  Cataract  Extraction 

most  part  in  slightly  different  form.  It  was  now  an  upper  flap, 
lying  just  in  front  of  the  limbus,  and  therefore  without  a  con- 
junctival flap.  De  Wecker  introduced  his  short  (3  millimetres) 
flap  in  1875.     But  the  fear  of  a  larger  section  being  allayed 


Fig.  10. — De  Wecker's  Incision. 

through  the  adoption  of  antiseptic  and  aseptic  measures,  and 
the  desire  for  simple  extraction  making  headway,  the  tendency 
soon  became  marked  to  enlarge  the  section  almost  or  quite  to 
the  old  semicircle. 

Thus,  the  main  events  in  the  history  of  cataract  extraction 
have  been  the  changes  which  have  taken  place  in  the  section — 
in  its  form,  its  site,  and  the  manner  of  making  it — also  changes 
depending  upon  the  character  of  the  section.  Procedure  in 
regard  to  the  question  of  iridectomy  or  no  iridectomy  has  in 
the  main  been  dependent  on  the  location  of  the  section.  The 
more  peripheral  the  section,  the  more  regularly  has  iridectomy 
been  needed.  In  other  matters  which  have  been  debated  in 
quite  recent  years  there  has  been  no  sweeping  unanimity  in 
opinion  or  practice.  The  question  of  simple  division  or 
removal  of  anterior  capsule,  except  as  decided  by  tenuity  or 
thickness  of  the  capsule,  is  a  comparatively  recent  one.  The 
method  of  subconjunctival  extraction  is  one  which  has  not  yet 
been  extensively  practised.  At  present  there  is  much  interest 
taken  in  the  intracapsular  operation,  owing  to  Major  Smith's 
extraordinary  work  at  Jullundur,  in  the  Punjab,  India. 


INSTRUMENTS. 

Lid  Retractors.  —  Some  form  of  stop  •  speculum  is  in 
almost  universal  use — at  least,  during  the  making  of 
the  section.  It  affords  the  widest  separation  of  the 
lids  with  the  least  inconvenience.  There  are  numerous 
varieties  of  the  instrument  in  use,  some  designed  to 
lie  over  the  nose,  others  over   the  temple.     The  latter 


Description  of  the  Operation 


29 


are  the  better  adapted  for  manipulation  by  the  assistant 
standing  in  the  usual  position,  close  to  the  eye  operated 
upon.       Among    them    Clark's    pattern    is    largely   used 


Fig.  II. — Clark's  Speculum. 

in  England.  It  is  simple  and  easily  cleaned,  fairly  light, 
but  strong  enough  to  resist  fairly  powerful  contraction 
of  the   orbicularis.     And   it   is   well   curved,  so   that   it 


Fig.  12. — Mellinger's  Speculum,  modified  by  Nettleship. 

liefe  ordinarily  close  in  to  the  temple.  The  arms, 
however,  are  locked  by  screw  adjustment.  This  is 
regarded  by  many  as  a  serious  defect,  since  it  does  not 


so  Cataract  Extraction 

allow  of  very  rapid  removal  of  the  instrument  when  in 
use.  Landolt's  models — one  nasal,  one  temporal — are 
fixed  by  a  small  lever  and  rack,  worked  by  simple  pressure 
of  the  finger.  The  arms  of  Mellinger's  and  Roster's 
ingenious  instruments,  working  by  rack  mechanism,  can 
be  approximated  at  once  for  withdrawal  by  simple  pressure 
between  the  finger  and  thumb  of  one  hand  ;  yet  they 
effectually  resist  pressure  exerted  by  the  lid  muscle.  They 
are  said,  however,  to  produce  too  wide  a  separation  of  the 
lids  in  some  cases.  Other  patterns  provide  for  easy 
removal,  but  do  not  control  the   lids   so  well.     Muller's 


Fig.  13.— Gaupillat's  Speculum. 

instrument    closes     and     falls     away    automatically    on 
powerful  contraction  of  the  orbicularis. 

Some  specula  are  fitted  with  solid  curved  end-plates  to 
cover  the  lashes  and  lid-borders,  either  fixed,  as  in  Lang's 
modification  of  Clark's  speculum,  or  movable,  as  in 
Terson's  and  Gaupillat's  models.  In  one  of  Lang's 
modifications  there  is  a  guard  for  overhanging  upper  lid. 
Other  specula  have  simple  bars  as  guards  for  the  lashes. 
The  benefit  of  such  coverings  is  seen  mainly  in  using  a 
keratome  for  an  upper  section,  in  performing  simple 
iridectomy  or  a  linear  extraction.  It  is  scarcely  appre- 
ciable in  an  ordinary  flap  extraction.  In  Landolt's 
instrument  only  two  hooks  pass  behind  the  border  of  each 
lid,  the  bar  connecting  them  lying  in  front  of  the  lid; 


Description  of  the  Operation  31 

that    is,    the    usual    arrangement    in   this    respect    is   re- 
versed. 

In  specula  of  any  pattern  the  curve  of  the  bar  or  end- 
plate,  upon  which  the  security  of  the  hold  on  the  lid 
depends,  may  be  a  little  too  open  and  shallow.  The 
instrument  is  thus  more  easily  removable.  But  the  gain 
in  this  respect  is  obtained  at  a  slight  risk  of  the  instrument 
slipping  from  between  lax  eyelids  when  it  is  at  all  forcibly 
elevated  by  the  assistant.  Even  the  leverage  of  the 
weight  of  the  unsupported  instrument  may  cause  it  to 
slip  out  from  the  lids  of  patients  with  narrow  faces,  for 
whom  the  curve  of  the  arms  is  insufficient.   The  inner  ends 


Fjg.  14.— Desmarres'  Retractors,  Small  and  Medium  Sizes. 

of  the  arms  are  seen  to  be  tilted  forward,  and  the  lower 
lid  gradually  slipping  back  before  the  instrument  finally 
escapes.  On  this  account  a  few  specula — e.g.,  Webster 
Fox's  modification  of  Clark's  instrument  and  Galezow- 
ski's  and  Gaupillat's — have  jointed  arms. 

Of  single  retractors,  Desmarres'  is  probably  most  used. 
For  cataract  work  the  small  or  middle  size  is  selected, 
and  is  used  for  the  upper  lid  alone,  the  lower  lid  being 
depressed  by  the  assistant's  finger.  The  pliable  German 
silver  stem  should  be  bent  as  shown  in  Fig.  41,  so  that 
the  recurved  end  portion  of  the  plate  is  parallel  with  the 
handle.  If  this  be  not  done,  the  lid  cannot  be  drawn 
sufficiently  forward  without  the  assistant's  hand  being  too 
close   to   the   eye,   inconveniencing   the   operator.      The 


32 


Cataract  Extraction 


separation  of  the  lids  thus  secured  is  not  so  wide  as  with 
the  stop-speculum,  but,  on  the  other  hand,  fairly  efficient 
control  is  afforded  over  the  lid  muscle. 

McGillivray's  or  Pellier's  wire  loops  may  be  employed 
instead,  or  a  large-sized  strabismus  hook,  as  used  by 
Smith  (Jullundur).  The  objection  to  the  simple  hook  is 
that  it  tends  to  pull  the  outer  canthus  and  outer  part  of 
the  lid  against  the  globe. 


Fig.  15. — Fixation  Forceps. 

Fixation. — Forceps  used  for  holding  the  eye  should 
have  strong  blades  which  will  not  bend  easily,  but  a  weak 
spring  which  will  not  tire  the  fingers  quickly.  The  usual 
two  teeth  on  one  blade  and  three  teeth  upon  the  other 
commonly  afford  a  sufficiently  firm  grip  of  the  conjunctiva 
without  tearing  it.     Broader   ends   and   more  numerous 


Fig.  16.— Landolt's  Fixation  Forceps. 

teeth  would  not  generally  give  a  more  secure  grip,  because 
the  forceps  have  to  be  applied  more  or  less  obliquely  to 
the  surface  of  the  globe.  With  eyes  deeply  set  and  turned 
well   downwards  the   obliquity  is  often  extreme,  so  that 


)»= 


13 


Fig.  17.— Fixation  Hook,  by  Bader. 

the  whole  breadth  of  the  ends  of  the  ordinary  forceps  is 
not  engaged.  Landolt  uses  forceps  with  obliquely  placed 
ends.     In  Bader's  and  Critchett's  models  each  blade  ends 


Description  of  the  Operation  3 


o 


in  a  single  sharp  claw,  capable  of  fixing  deeply  in  the 
episcleral  tissue.  Weiss  makes  a  pattern  with  three  such 
claws  on  each  blade  instead  of  teeth.  The  double  hook 
shown  in  Fig.  17  is  practically  the  same  as  the  old 
Pamard's  spear,  recommended  for  fixation  after  the  con- 
junctiva has  become  torn. 

The  Knife. — Graefe's  knives  in  various  breadths  are 
almost  the  only  ones  used  nowadays  for  flap  extraction. 


""—^ 


Fig.  18. — The  Graefe  Knife. 

The  handle  should  be  of  ivory  or  aluminium.     Steel  is 
too  heavy,  and  too  slippery  when  wet. 

Sir  Anderson  Critchett  uses  a  knife  slightly  modified  from 
the  Graefe  pattern.  *'  The  back  of  the  knife  is  bevelled  and 
the  blade  is  slightly  rounded ;  it  does  not  permit  of  too  rapid 
escape  of  aqueous."*  Kuhnt's  knife  is  also  designed  to  retain 
aqueous.  For  6  millimetres  from  the  point  it  resembles  an 
ordinary  Graefe's  blade,  and  then  broadens  out  into  the 
triangular  Beer  form.  Bell  Taylor's  trowel-shanked  knives 
permit  of  the  right  hand  being  used  upon  the  left  eye,  the 
surgeon  standing  behind  the  patient's  head,  and  puncturing  at 
the  nasal  margin  of  the  cornea. 

Iris  Forceps. — The  pattern  entered  in  the  catalogues 

FULL  SIZE.  


Fig.  19. — Iris  Forceps. 

as  "  curved,  rectangular,  with  tenaculum  points,"  is  very 
serviceable.  With  less  curved  blades  there  is  more  danger 
from  upward  movements  of  the  globe  while  the  ends  of 

*  T^e  Ophthalmoscope^  iv  (1906),  112. 

3 


34  Cataract  Extraction 

the  forceps  are  within  the  wound.  The  ends  of  the  forceps 
when  closed  must  be  smooth,  in  order  not  to  catch  in  the 
iris. 

A  Tyrrell's  Hook  may  be  of  service  occasionally,  should 
the  iris  be  buttonholed. 


Fig.  20— Tyrrell's  Hook. 


Of    Iris   Scissors,    de    Wecker's    spring    scissors    are 
perhaps  the  most  convenient.     Scissors  of  the  ordinary 


Fig.  21. — De  Wecker's  Iris  Scissors. 


Fig.  22.— Elbowed  Iris  Scissors. 

pattern  should  be  '  elbowed '  for  use  on  the  right  eye, 
straight  for  use  on  the  left  eye. 

Cystitomes,  etc. — A  straight  instrument  for  opening  the 
capsule  may  be  difficult  to  use  in  a  deeply  placed  eye  unless 
the  globe  be  turned  fully  downwards. 

Capsule  Forceps.  —  Couper's  forceps  differ  from 
ordinary  iris  forceps  in  having  a  number  of  small  teeth 


Description  of  the  Operation  35 


Fig.  23. — Straight  Iris  Scissors. 


F^ 


Fig.  25.— Moorfields  Pattern  Cystitome. 


Fig.  26.— Weber's  Capsular  Hook. 


Fig.  24. — Graefe's  Bent 

Cystitomes,  Right  and 

Left. 


Fig.  27.— Rectangular  Lens  Hook. 


Fig.  28. — Terson's  Capsular  Forceps. 


Fig.  29. — Treacher  Collins'  Capsule  Forceps. 

3—2 


3'6 


Cataract  Extraction 


along  a  portion  of  the  lower  margin  of  each  blade  near  its 
point.  De  Wecker's  instrument  has  the  usual  teeth  at 
the  ends,  like  iris  forceps,  and,  in  addition,  each  blade  has 
a  small  tooth  projecting  down  from  its  lower  edge.  The 
blades  of  Terson's  forceps  are  slightly  curved  beyond  the 
bend,  to  correspond  with  the  posterior  surface  of  the 
cornea.  The  blades  remain  separated  at  the  bend  when 
closed  at  the  point,  and  the  teeth  are  few  in  number. 
Thus  they  are  not  likely  to  grip  the  iris  when  used  in 
simple  extraction.  L.  Muller's  forceps  remain  open 
similarly  at  the  bend.  Rochon-Duvigneaud's  forceps  are 
similar  to  Terson's,  but  each  blade  has  numerous  teeth 
extending  from  the  point  to  the  bend.     Treacher  Collins' 


Fig.  31. — ToRTOisESHELL  Spoon. 


Fig.  32. — Pagenstecher's  Spatula. 


pattern  is  like  the  Fischer-Arlt  iris  forceps,  but  with  a 

number  of  teeth  arranged  for  seizing  the  capsule. 

I      Lens   Expressors.  —  I    have   followed   Mulroney   and 

/- 1  Smith,  of  the  Indian  Medical   Service,  in  using  a  large 

/jtenqtomy   hook   for   expressing   the   lens.     The   hook   is 

impipved  by  increasing  its  curve  nearly  to  a  semicircle,* 

\ 

*  Ec^sily  done  after  heating  the  instrument  in  the  flame  of  a  spirit- 
lamp. 


Description  of  the  Operation  37 

as   shown    in    Fig.    41.     And   I   have  had  one  made  by- 
Weiss,  thickened  and  a  Httle  flattened  about  the  curve, 
^to  broaden  the  surface   mostly  used.     The  curve  corre- 
'  sponds  fairly  well  with  the  circumference  of  the  cornea 


Fig.  33.— Iris  Repositor. 

and  of  the  lens,  and  is  therefore  particularly  suited  for  the 
alternation  of  pressure  and  indentation,  at  either  side  and 
below,  by  simply  rocking  the  instrument.     But  the  same 


Fig.  34.— Curette. 

shifting  of  the  pressure  may  be  obtained  with  less  curved 
instruments  by  sliding  them  from  place  to  place.  The 
point  is  obviously  of  only  minor  importance.     The  well- 


FiG.  35. — Snellen's  Vectis. 

established  tortoiseshell  spoon  is  fairly  well  suited  for  the 
work,  but  its  curve  might  well  be  increased,  and  the  edge 
of  the  bowl  is  not  sufficiently  thick  and  rounded,  and  is 


0= — — =*^ 


Fig.  36.— Taylor's  Vectis. 

not  quite  in  the  same  plane  as  that  of  the  stem  close  to 
the  bowl.  Various  curettes  and  spatulae  are  also  used — 
straight,  curved,  and  bent  at  an  angle.  Pagenstecher  uses 
a  curved  glass  spatula. 


38 


Cataract  Extraction 


For  assisting  in  the  delivery  of  the  lens  by  supporting 
it  when  the  zonule  has  been  ruptured,  Bowman's  or 
Critchett's  or  Pagenstecher's  spoon  may  be  needed.  The 
two  former  are  flat  from  side  to  side,  being  curved  only 
in  the  one  direction.  They  are  well  suited  for  holding 
back  the  vitreous,  and  Bowman's,  with  fine  grooving  only 
at  its  extremity,  is  better  suited  for  passing  down  between 
lens  and  vitreous  than  Critchett's,  with  thickened  rim. 


Fig.  37. — Bowman's  Spoon. 


Pagenstecher's  bowl  is  unnecessarily  large  for  supporting 
the  lens,  but  is  possibly  better  for  actually  extracting  the 
lens.  For  this  purpose,  however,  Snellen's  or  Taylor's 
wire  loop  is  well  adapted.  One  of  these  instruments 
should  always  be  at  hand,  to  be  rapidly  sterilized  in  the 
flame  in  case  of  necessity. 

Iris   Repositors.  —  A   flat   spatula,  such  as   shown   in 
Fig-  33>  is  in  common  use.     I  have  used  a  curette  in  order 


Fig.  38.— Pagenstecher's  Spoon. 

not  to  add  to  the  number  of  instruments  in  use.  It  is  of 
the  pattern  shown  in  Fig.  34.  The  groove  in  its  concave 
surface  should  be  shallow  and  its  edges  thick  and  rounded, 
and  the  curette  itself  not  broad.  Being  made  of  German 
silver,  the  instrument  is  sufficiently  pliable  to  be  easily 
bent  by  the  fingers.  It  may  be  used,  not  only  for 
replacing  iris,  but  also  in  simple  extraction  for  applying 
counter-pressure   above  the  wound.      For   this   purpose, 


Description  of  the  Operation  '  39 

used  upon  the  right  eye  and  held  in  the  left  hand,  the 
instrument  must  be  considerably  curved.  We  also  em- 
ployed the  curette  for  removing  mucus  from  the  palpebral 
conjunctival  surface  at  the  close  of  the  operation,  and 
very  occasionally  at  the  beginning  of  the  operation  to 
detach  mucus  lying  in  the  recesses  about  the  plica. 

Irrigators  for  douching  the  anterior  chamber.  The 
ordinary  laboratory  '  wash-bottle  '  arrangement  of  flask 
and  glass  tubing  served  us  in  Bombay  for  over  ten  years. 


P^iG.  39. — I.  Irrigator  Flask.    2.  Nozzle.    3.  Mouth  Screen. 

fitted  with  an  extension  of  rubber  tubing,  i|  to  2  feet 
long,  and  a  readily  removable  silver  nozzle.  This  was  the 
locally  obtainable  substitute  for  McKeown's  more  elaborate 
apparatus. 

At  first  we  used  to  blow  into  the  flask  through  a  plug  of 
sterilized  wool  to  start  the  syphon  action.  Afterwards  we  used 
a  ball  syringe  (not  shown  in  the  figure)  to  start  the  flow.  Each 
flask  of  fluid  frequently  served  for  half  a  dozen  operations,  and 
the  syphon  action  once  started  was  usually  kept  going  with- 
out stoppage  throughout,  the  fluid  being  retained  in  the  outflow 


40  Cataract  Extraction 

tube  between  the  successive  operations.  Thus  the  rubber  ball 
was  only  attached  for  the  moment  when  it  was  needed.  The 
tubing,  glass  and  rubber,  was  kept  in  strong  perchloride  lotion 
always  when  not  in  use,  and  the  same  fluid  was  passed  into  the 
tubes  by  syphon  action,  and  retained  there  by  a  clamp  some 
hours  before  operating.*  The  small  nozzle  was  made  of  silver, 
sufficiently  pure  that  it  did  not  blacken  when  heated  in  the 
flame  of  a  spirit-lamp.  The  array  of  cannulae  supplied  with 
McKeown's  apparatus  was  not  found  necessary. 

Lippincottf  passes  the  rubber  tubing  close  to  the 
nozzle  through  a  holder  provided  with  a  '  shut-off,'  to 
prevent  backward  flow  when  the  reservoir  is  allowed  to 
drop  below  the  tip  of  the  tube. 

A  simpler  apparatus,  which  has  been  used  by  Wicker- 
kiewicz,  Uhle,  and  others,  is  the  '  undine,'  a  retort-like 
flask  with  long  bent  outflow  tube,  bearing  a  nozzle.  The 
pressure  of  the  outgoing  stream  is  changed  by  altering 
the  inclination  of  the  flask. 

f  Simple  pipettes  with  rubber  nipples — ordinary  medicine 
'  droppers — have  also  been  employed,  sometimes  fitted  with 
nozzles.  On  the  same  principle,  large  rubber  bulbs  have 
been  used  by  Kuhnt  and  Wanless  (Miraj,  India).  It  is 
I  stated  that  these  rubber  syringes  may  throw  bubbles  of 
/  j  air  into  the  eye,  and  the  force  of  the  current  produced 
by  compression  of  the  bulb  cannot  be  so  accurately 
measured  as  when  the  propelling  force  is  simply  gravity. 
An  advantage  claimed  for  the  rubber  ball  is  that  it  can  be 
used  with  one  hand,  enabling  one  to  dispense  with  an 
attendant.  Wanless's  bulbs  are  fitted  with  McKeown's 
cannulae  by  bayonet-joint  attachments. 

Piston  syringes  are  somewhat  liable  to  be  out  of  order 

*  It  is  obvious  that  the  irrigating  fluid  which  first  passed  through 
these  tubes  from  the  flask  must  have  contained  a  trace  of  perchloride, 
and  was  therefore  fit  for  use  only  on  the  surface  of  the  globe. 

t  Anier.  Journ.  of  Ophth.,  xxi  (1904),  193. 


/ 


Description  of  the  Operation 


41 


when  needed,  and  with  them  the  force  of  the  current  is 
more  difficult  to  regulate  than  with  ball  syringes.  But 
the  double-current  instrument  introduced  by  Chibret*  in 
1895  stands  in  a  class  by  itself.  Its  essential  principle 
is  that,  by  its  double  cannula,  fluid  is  sucked  out  of  the  eye 
in  quantity  equal  with  that  introduced.  Thus  the  tension 
within  the  chambers  remains  unaffected  unless  the  outflow 
tube  should  become  blocked.  Chibret's  syringe  is  made 
by  Aubry.  Lagrange  and  Aubarett  use  a  very  similar 
instrument  made  by  Creuzen  and  Soulard,  47,  Cours 
de  I'lntendance,  Bordeaux. 


Fig.  40. — Double  Current  Syringe,  by  Lagrange  and 

AUBARET. 


Intra-ocular  irrigation  is  intended  primarily  for  washing 
away  cortical  remains,  but  is  useful  also  for  removing 
blood,  iris  pigment,  or  a  piece  of  iris  isolated  by  the 
knife,  also  air  bubbles.  The  stream  of  fluid  can  be  em- 
ployed also  for  douching  the  conjunctival  sac  before 
operation,  and  for  keeping  the  cornea  moist  during  opera- 
tion. It  has  been  used  also  for  filling  the  anterior  chamber 
in  eyes  with  collapsed  cornea,  whether  after  loss  of  vitreous 
or  not.  The  fluid  in  general  use  is  physiological  salt 
solution,  0*7  per  cent.  Lagrange  and  Aubaret,  desiring 
a  closer  approximation    to   tne   composition  of  aqueous 

*  Afi7t.  d' Ocu/.,  c^n  (1895),  120. 
t  Arc/t.  d'Op/i/L  farrier,  1905. 


42  Cataract  Extraction 

humour,  use  the  following:  Water  i,ooo,  sodium  chloride 
6*8go,  calcium  chloride  0*113,  potassium  sulphate  o"22i. 
The  solution  must  be  sterilized,  and  should  be  used  at  a 
temperature  a  few  degrees  above  blood-heat  in  the  flask, 
to  allow  of  a  little  cooling  as  it  passes  through  the 
tube. 

Chibret  used  i  part  of  cyanide  of  mercury  in  20,000 
boric  acid  solution.  He  injected  20  to  30  grammes  of 
fluid — i.e.,  three  or  four  times  the  contents  of  his  syringe. 


GENERAL  ARRANGEMENTS. 

For  the  general  arrangements — fittings,  furniture,  lighting, 
etc.— of  the  operating  room,  works  on  eye  operations  in  general 
must  be  consulted.  The  conditions  under  which  most  suc- 
cessful work  is  done  in  India  would  astonish  surgeons  accus- 
tomed only  to  the  elaborate  provisions  for  asepsis  in  well  fitted 
hospitals.  But  in  India  much  of  the  work  is  done  practically 
in  the  open.  The  windows  are  kept  constantly  open,  so  far  as 
the  strength  of  the  prevailing  wind  allows,  and  this  renders  of 
no  account  dirty  surroundings,  furniture,  patients,  and  assist- 
ants. The  operating  room  in  Bombay  was  the  out-patient 
room  just  cleared  of  the  morning  crowd  of  out-patients. 

In  our  private  work  at  patients'  houses  sometimes  every- 
thing in  the  room  was  more  or  less  filthy,  and  the  floor  perhaps 
cow-dunged,  so  that  care  had  to  be  taken  to  avoid  raising  any 
dust  in  the  room.  The  light  was  sometimes  poor,  from  small, 
low  windows,  opening  on  to  a  verandah,  or  partly  covered  by 
weather-boards.  The  light  from  a  small  window  near  at  hand 
is  ample,  if  other  sources  of  light  are  shut  off  to  avoid  multiple 
corneal  reflexes,  and  if  the  window  be  sufficiently  high  ;  and 
it  should  face  away  from  the  sun,  lest  there  be  any  dazzling 
reflexion  from  below. 

Unless  the  operation  can  be  performed  upon  the  patient's 
bed,  some  provision  must  be  made  for  placing  the  patient  in 
bed  afterwards  without  any  effort  from  him.  An  ordinary 
domestic  table,  with  a  few  coverings  and  a  single  pillow, 
generally  places  the  patient's  head  at  a  convenient  level,  so 


y. 


Description  of  the  Operation  43 

that  the  surgeon,  standing  upright,  or  nearly  so,  may  work 
with  forearms  flexed  at  rather  less  than  a  right  angle.  The 
coverings  should  be  sufficiently  strong  to  support  the  patient's 
weight  when  he  is  being  carried  to  bed.  A  small  table  must 
be  placed  near  the  patient's  head  during  operation,  for  the 
instrument  tray  and  for  a  bowl  of  lotion. 


THE  PREPARATION  OF  THE  PATIENT. 

On  admission  the  ordinary  hospital  rules  as  to  cleanli- 
ness are  observed,  paying  especial  attention  to  the  washing 
of  the  eyelids  and  neighbouring  parts.  A  laxative  is  ad- 
ministered, and  the  patient's  control  over  his  eye  and  lid 
movements  tested,  and  developed  so  far  as  practicable. 

In  testing  the  patient's  self-control,  he  is  required  to 
keep  his  eyes  turned  steadily  downwards  while  the  lids 
are  lightly  manipulated,  and  while  eversion  of  the  upper 
lid  is  carried  out.  Most  of  them  at  first  roll  their  eyes  up 
and  close  their  lids  forcibly,  but  after  a  little  practice  have 
no  difficulty  in  curbing  these  impulses.  After  this  they 
can  almost  always  be  depended  upon  to  exercise  the 
necessary  restraint  during  operation.  Some  nervous, 
timid  people  require  training  for  a  day  or  two  to  become 
accustomed  to  the  demand  upon  their  will-power,  and 
then  behave  extremely  well. 

Patients  are  required  also  to  maintain  fixation  of  their 
eyes  in  different  directions,  following  movements  of  their 
hands.  In  this  test  the  eye  upon  which  operation  is  not 
contemplated,  if  it  be  a  seeing  eye,  is  screened  but  not 
closed.  The  patient  must  be  able  to  look  towards  his 
hand  without  seeing  it,  the  direction  of  his  eyes  being 
governed  by  muscular  sense.  Otherwise,  during  opera- 
tion the  eyes  are  apt  to  roll  upwards  as  soon  as  the 
vision  of  the  good  eye  is  cut  off  by  the  surgeon's  hand 
holding  the  fixation  forceps. 


44  Cataract  Extraction 

In  this  test  we  may  encounter  an  extraordinary  stupidity. 
Some  of  our  elderly  patients,  generally  cultivators  who  had 
been  blind  from  cataract  in  both  eyes  for  perhaps  a  few  years, 
had  so  lost  the  habit  of  fixation  that  they  could  not  be  induced 
to  rotate  their  eyes  as  directed.  Others,  through  lack  of  will- 
power, could  maintain  fixation  of  the  eyes  for  a  few  seconds 
only  in  any  position  but' that  of  rest.  Even  after  some  days' 
training  by  the  hospital  assistants,  some  very  stupid  people 
failed  to  look  downwards,  except  by  turning  their  heads  down. 
Formerly  much  time  was  wasted  upon  them,  and  in  a  few 
cases  the  extraction  was  performed  under  chloroform.  Latterly 
they  were  operated  upon  by  Czermak's  lower  section.  Nearly 
all  of  them  could  turn  their  eyes  a  little  upwards.  Fortunately, 
this  stupidity  is .  rarely  combined  with  nervousness ;  these 
patients  neither  roll  their  eyes  about  during  operation  nor 
squeeze  their  lids  together. 

A  *  Test  IJressiug '  should  be  applied  the  night  before 
operation  to  untreated  cases,  but  not  to  those  which  have 
been  treated  for  conjunctivitis.  It  need  consist  of  nothing 
more  than  a  strip  of  lint  or  gauze  fixed  over  the  lids  by  a 
single  turn  of  bandage.  Its  object  is  to  retain  on  the  lint 
and  on  the  lid  margins,  and  at  the  inner  canthus,  any 
discharge  which  may  form  within  the  conjunctival  sac 
during  the  night.  It  serves  simply  as  a  guarantee  that  all 
discharge  shall  be  visible  at  the  surgeon's  morning  in- 
.spection.  The  bandage  should  not  be  removed  before  the 
time  of  the  inspection,  or,  if  removed  earlier,  care,  must  be 
taken  that  the  lids  are  left  untouched,  and  that  the  bit  of 
lint  is  available  for  examination. 

An  Early  Morning  Inspection  of  the  patient  is  strongly 
advisable,  in  order  that  a  final  assurance  may  be  given  as  to 
tthe  fitness  of  the  eyes  for  operation.  Provided  that  satis- 
factory perchloride  irrigation  is  to  precede  operation,  cases 
with  chronic  conjunctival  changes  may  be  accepted  showing 
scanty,  thin,  dried  discharge  on  the  lid  borders,  or  an  ab- 
normally large  accumulation  of  mucus  at  the  inner  canthus. 


Description  of  the  Operation  45 

/But  an  additional  thread  or  flake  of  mucus  lying  in  the 
//lower  fornix  suggests  the  need  for  caution.  As  a  rule,  the 
operation  must  be  postponed  for  a  few  days'  treatment, 
or  at  least  the  decision  as  to  operation  must  be  deferred 
for  a  few  hours.  If  at  a  second  inspection  after  this 
interval — i.e.,  about  the  usual  hour  for  operating — any 
fresh  mucus  is  found  in  the  fornix,  operation  should  be 
postponed.  At  this  second  examination,  also,  one  may 
judge  to  what  extent  conjunctival  congestion  seen  on 
removal  of  the  bandage  was  due  simply  to  occlusion  of 
the  eye.  Such  congestion  will  have  disappeared  in  an 
hour  or  two,  and  any  injection  still  remaining  may  be 
attributed  to  the  presence  of  pathogenic  organisms. 
/Much  less  importance  attaches  to  scanty  discharge 
from  a  conjunctiva  roughened  and  thickened  by  very 
chronic  inflammationythan  from  a  membrane  nearly 
normal  in  appearan(5e.  For  in  the  former  instance,  not 
only  may  the  altered  mucous  membrane  be  expected  to 
withstand  very  vigorous  perchlor'de  douching,  but  we 
have  learnt  from  practical  experience  not  to  fear  the  result 
of  operation  performed  on  such  an  eye  after  the  suitable 
douching.  It  seems  reasonable  to  admit  that  such  con- 
junctivae may  furnish  a  little  abnormal  secretion  quite 
independently  of  the  action  of  any  existing  micro- 
organisms. And  it  is  a  matter  of  fairly  general  observa- 
tion that  in  very  chronic  conjunctivitis  the  only  pathogenic 
organisms  likely  to  be  found  are  staphylococci  of  feeble 
virulence  or  Morax-Axenfeld  diplobacilli.  And  there  ap- 
pears to  be  little  difficulty  in  getting  rid  of  diplo-bacilli — 
temporarily  at  least  (see  Chapter  IV,  Asepsis).  We  are 
much  more  afraid  of  quite  recent  conjunctival  changes — 
slight  injection,  with  a  mere  trace  of  thickening  and  rough- 
ness and  of  discharge.  We  fear  these,  knowing  from  bac- 
teriological examination  that  the  conjunctivae  of  some  of 


46  Cataract  Extraction 

the  eyes  upon  which  we  operated  contained  numerous 
pneumococci  or  streptococci. 

Occasionally,  in  up-country  j^atients,  we  decided  to 
operate  in  the  presence  of  chronic  inflammation  with 
distinctly  freer  discharge  than  above  mentioned.  In 
these  cases  preliminary  perchloride  irrigation  was  practised 
at  the  time  of  inspection,  lasting  perhaps  ifer_Jen  seconds. 
The  lotion^  -iB_^°*-*°'  ^^^  squeezed  out  of  pads  of  lint, 
and  the  cases  were  noted  for  the  maximum  treatment  just 
before  operation. 

In  our  private  practice  infective  iritis  and  irido-cyclitis 
have  been  rather  more  frequent  than  in  hospital  work,  and 
we  have  thought  that  the  higher  incidence  was  possibly 
accounted  for  by  the  non-use  of  the  test  dressing  and 
morning  inspection. 

To  show  fitness  for  operation  without  antiseptic  lotion, 
the  test  bandage  must  reveal  no  trace  of  abnormal  secre- 
tion. 

At  the  morning  examination,  also,  tha  opportimity  may 
be  taken  of  testing  the  patient's  controPtjfHtlis  eye  and 
lid  movements.  Operation  may  have  to  be  postponed  for 
further  training  of  the  patient.  The  administration  of  a 
nervfevseuative  may  be  found  advisable  to  dull  an  excitable 
patient's  fears ;  or  operation  by  lowe^^ction,  preferably 
subconjunctival,  may  be  decided  upon  in  the  case  of  a 
very  unintelligent  individual. 

Orders  can  also  be  given  now  as  to  the  perchloride 
treatment  of  the  conjunctiva  immediately  before  operation, 
the  instillation  of  adrenalin,  etc. 

For  nervous  patients  a  bromide  draught  at  night  may  be 
possibly  advisable.  A  good  night's  rest,  plus  some  of  the 
influence  of  the  drug  still  remaining,  must  help  to  make  the 
patient  collected  and  calm  for  the  ordeal.  At  times  we  have 
used  bromide  and  chloral  fairly  extensively,  lo  or  15  grains  of 


Description  of  the  Operation  47 

each,  but  given  an  hour  or  two  before  operation.  The  effect 
was  often  very  noticeable.  Morphia  and  other  sedatives  have 
been  used  also,  with  the  object  of  lessening  the  risk  of  prolapse 
of  iris  after  simple  extraction, 
t\j  General  anaesthesia  by  hypodermic  injection  of  scopolamine 
^^  /and  morphine  has  been  recommended  in  nervous  and  restless 
patients  (Chapter  IV). 

PRELIMINARIES. 

The  point  and  edge  of  the  knife  are  tested  upon  a 
leather  drum.  The  selected  instruments  must  be  cleaned 
and  sterilized,  and  laid  in  order  on  a  rack.  The  hands 
of  the  surgeon,  of  the  assistant,  and  of  the  attendant 
are  washed  thoroughly  and  steeped  in  perchloride  lotion. 
The  assistant  bathes  the  skin  of  the  lids  and  surrounding 
parts,  and  (following  a  practice  now  given  up  by  many) 
douches  the  conjunctival  sac  with  perchloride  lotion,  and 
follows  this  by  the  instillation  of  cocain  solution.  In 
many  cases  the  use  of  adrenalin  chloride  solution,  before 
or  with  the  cocain,  is  of  benefit.  The  surgeon  and  the 
assistant  don  mouth  masks. 

The  instruments  commonly  required  are  shown  in  Fig.  41, 
plus  the  Desmarres'  retractor,  which  is  only  quite  exception- 
ally needed.  In  addition,  a  Bowman's  spoon  or  a  wire  loop 
should  be  at  hand,  and  perhaps  also  a  Tyrrell's  hook.  Some 
surgeons  would  replace  the  cystitome  by  capsule  forceps.  A 
sharp  hook  might  rarely  be  wanted  also. 

The  Sterilization  of  Instruments  in  eye  work  is  commonly 
by  boiling  in  water,  or,  better,  in  i  per  cent,  soda  solution.  The 
only  difficulty  is  with  the  knife,  which  loses  its  edge  by  repeated 
boiling.  Where  a  number  of  operations  have  to  be  performed 
in  succession,  more  than  one  set  of  instruments  is  ordinarily 
required.  For  example,  Elliot's  arrangement  in  Madras  is 
this :  He  has  a  rectangular  sterilizer  22  inches  long,  6*5  inches 
broad,  and  5*5  inches  deep.  This  holds  four  perforated 
aluminium  instrument  trays,  each  of  them  5*5  inches  long, 
5  inches  broad,  and  i'5  inches  deep.     Each  has  handles  at  the 


48 


Cataract  Extraction 


two  ends,  by  which  it  is  hfted  out  of  the  boiHng  water  with  the 
aid  of  metal  hooks.  This  allows  for  one  tray  to  be  on  the 
table  containing  the  instruments  in  use,  one  to  be  cooling  (in  a 
cloth  wrung  out  of  i  in  3,000  biniodide  solution),  and  two  to  be 
boiling.  This  gives  each  set  of  instruments  ten  minutes'  boiling. 
Neither  knife  nor  scissors  are  sterilized  upon  these  trays ; 
their_points  are  immersed  by  an  assistant  for  two  minutes  in 
the  boiling  water  of  the  sterilizer. 

Many  surgeons,t-^^,  de  Weaker,  Lagrange,  de  Lapersonne, 
True — prefer  dryneat  (130°  to  150°  C.  in  a  stove  for  an  hour). 


Fig.  41. — Instruments  laid  out  for  Cataract  Extraction. 

Stop-speculum  ;  fixation  forceps ;  strabismus  hook  (expressor) ; 
curette,  used  also  as  repositor  ;  Graefe's  cystitome,  point  downwards  ; 
de  Wecker's  scissors  ;  iris  forceps  ;  knife  ;  curved  scissors  for  eyelashes  ; 
Desmarres'  retractor. 

Louis  Dor  and  Rollet  (Lyons)  sterilize  in  boiling  oil  at  140°  C. 
The  oil  is  freed  from  oleic  acid  by  maceration  for  twenty-four 
hours  in  absolute  alcohol. 

At  the  C.  J.  Hospital,  Bombay,  we  depended  on  the  flame 
of  a  spirit-lamp  for  sterilizing  the  points  of  cystitome  and  of 
conjunctival  and  iris  forceps,  the  curette  and  expressor  hook, 
and  the  nozzle  of  the  irrigator.    Simple  washing  with  sterilized 


J 


Description  of  the  Operation  49 

lint,  soap,  and  carbolic  lotion,  i  in  60,  was  made  to  suffice  for 
the  knife,  scissors,  speculum,  and  retractor. 

This  practice  was  begun  at  a  time  when  the  work  was  less 
heavy  than  it  afterwards  became,  when  the  assistants  were 
untrained,  and  when  we  had  only  a  small  supply  of  instru- 
ments, and  no  sterilizer.  The  one  set  of  instruments  was  used 
for  the  whole  morning's  work,  and  I  had  to  be  personally 
responsible  for  all  details  of  any  importance.  The  method 
proving  reliable  and  on  the  whole  satisfactory,  it  was  con- 
tinued. But  the  few  minutes  of  time  wasted  between  one 
operation  and  the  next  could  not  be  well  spared,  and  on  this 
account  other  arrangements  were  being  made.  The  details 
may,  however,  be  of  use  to  others  in  circumstances  such  as 
ours. 

Details  of  Sterilization  in  the  Flame. — To  minimize  the  slow 
destruction  of  the  iris  forceps,  and  especially  of  the  cysti- 
tome,  by  the  repeated  heating,  the  points  of  these  instru- 
ments were  allowed  to  remain  in  the  flame  for  a  period  just 
short  of  that  necessary  to  make  them  red  hot.  A  trace  of 
black  oxidized  metal  had  to  be  scraped  off  them  occasionally. 
Since,  as  it  happened,  our  tenotomy  hooks  and  curettes  had 
bone  handles,  these  instruments  had  to  be  rapidly  cooled  after 
heating  by  being  plunged  into  a  bowl  of  carbolic  solution. 
The  irrigator  nozzle  held  in  the  fixation  forceps  needed  to  be 
heated  to  a  dull  red  before  the  first  operation  of  the  day,  in 
order  to  burn  away  matter  in  its  lumen.  It  was  also  cooled 
by  immersion  in  the  fluid  to  save  time.  Afterwards,  between 
one  operation  and  the  next,  the  nozzle  was  not  removed  from 
the  rubber  tube.  Only  its  tip  was  placed  in  the  flame,  the  fluid 
being  drawn  back  from  it  by  a  slight  sliding  movement  of  the 
finger  and  thumb  which  held  the  rubber  tubing.  It  was  only 
heated  enough  to  give  a  hissing  sound,  when  a  little  fluid  was 
allowed  to  spurt  through  it  to  cool  it  again. 

Some  of  the  nozzles  used  were  rather  short  for  this  heating 
of  their  tips,  while  still  attached  to  rubber  tubing.  The  interior 
of  the  tubing  immediately  beyond  the  metal  got  roughened 
after  a  time,  and  unless  it  were  cut  away,  small  particles  of 
rubber  were  apt  to  be  thrown  into  the  eye  by  the  stream  of 
fluid  passing  through.  A  few  such  particles  were  left  in  eyes, 
fixed  by  blood-clot,  but  they  gave  rise  to  no  irritation,  and 
were  slowly  absorbed. 

4 


.c^ 


50  Cataract  Extraction 

In  depending  upon  simple  washing  of  the  knives  and  iris 
scissors,  it  was  realized  that  some  responsibility  was  incurred. 
The  first  washing  of  the  day  was  in  particular  very  thorough, 
so  much  so  that  the  knife  edges  probably  suffered  quite  as 
much  as  if  they  had  been  plunged  into  boiling  water  in  the 
usual  fashion. 

We  used  our  instruments  dry,  simply  laid  out  upon  a  rack 
as  they  were  got  ready.  It  is  more  usual  to  immerse  them  in 
sterile,  unirritating  fluid  before  and  during  the  operation.  Such 
fluid  must,  of  course,  be  changed  after  every  operation. 

Antiseptic  lotions  must  be  always  made  the  day  before  use, 
or  earlier.     Drops  for  instillation  should  be  freshly  prepared, 
and  boiled  for  three  to  five  minutes  in  Stroschein's  or  other 
CM^^      Isuitable  bottles.     Boiling  once  for  five  minutes  has  been  found 
C/^      Li/*'\/not  to  impair  the  action  of  the  ordinary  cocain  solution. 
f^^nr  During  operation  the  curette  in  particular  frequently  needs 

'  cleansing  again  more  than  once.     It  is  washed  with  bits  of 

lint  taken  from  the  bowl  of  perchloride  lotion  standing  near 
the  patient's  head.  It  is  then,  after  rinsing  in  a  stream  of 
saline  fluid  from  the  irrigator,  fit  for  entry  within  the  wound. 
Similar  treatment  suffices  also  for  the  nozzle  of  the  irrigator, 
should  its  steriHty  have  been  rendered  doubtful  by  contact  with 
the  conjunctival  surface.  This  friction  with  wet  sterile  lint 
may  be  depended  upon  to  remove  any  moist  (and  therefore 
loosely  adherent)  material  with  which  these  instruments  might 
have  become  soiled  during  the  progress  of  the  operation. 
Should  any  toothed  instrument  need  sterilizing  quickly  in  an 
emergency,  it  may  be  passed  through  the  flame  of  a  spirit- 
lamp. 

Lippincott '■'  advises  continuous  sterilization  of  knives  in  a 
20  per  cent,  solution  of  formol,  containing  3  per  cent,  of  borax. 
The  knives  are  placed  in  perforated  steel  boxes  in  the  solution, 
and  before  use  are  rinsed  in  sterilized  borax  solution  and 
wiped  with  sterile  cotton.  Each  knife  can  thus  be  used  only 
once  in  a  day.  Lippincott  found  alcohol  ineffectual  for 
sterilizing  purposes.  Asmus  recommends  similar  continuous 
sterilization  in  the  spintus  saponaUis  of  the  Prussian  Pharma- 
copoeia. [For  its  composition,  see  The  Ophthalmoscope,  (1904) 
ii,  294]. 

*  Arch.  ofOphth.,  July,  1898. 


Description  of  the  Operation  51 

Perchloride  Irrigation. — In  attempting  to  clear  away 
micro-organ isjjis  from  the  operative  field,  we  have  douched 
with  I  m-j^^o  perchloride  lotion.  Since  the  reaction  of 
the  conjunctiva  varies  greatly  according  to  the  condition 
of  the  latter,  systematic  efforts  were  made  to  keep  the 
effect  nearly  uniform  by  varying  the  period  of  irrigation. 
Practically  normal  conjunctivae  were  treated  ior_i  to  i^ 
minute;  others  for  periods  up  to  ifminute.  The  time 
was  regulated  by  our  estimate  of  the  amount  of  douching 
which  the  particular  mucous  membrane  would  withstand 
without  excessive  reaction.  The  shorter  application,  one 
minute,  was  not  found  to  be  too  severe  for  the  most 
delicate  conjunctiva,  whereas  the  longer  treatment  was 
still  quite  insufficient  for  some  scarred  or  roughened  and 
thickened  mucous  membranes.  For  these  a  short  sup- 
plementary douching  was  added  after  the  cocain  instil- 
lation. 

This  one  particular  concentration  of  the  lotion  was  in 
almost  regular  use  at  the  Bombay  Hospital  for  ten  years 
or  more.  But  it  is  not  recommended  as  certainly  the 
most  suitable  strength.  We  tried  stronger  solutions, 
I  in  2,000  and  i  in  2,500,  correspondingly  reducing  the 
quantity  used ;  but  we  did  not  obtain  quite  the  same 
result.  There  was  more  inflammatory  swelling  of  the 
lids  and  conjunctiva,  and  this  deep  reaction  was  precisely 
what  we  wished  to  avoid.  On  the  other  hand,  weaker 
solutions  used  more  freely  should  give  more  of  the  super- 
ficial action  which  is  desired.  /^For  instance,  the  ordinary 
I  in  5,000  solution,  employed  for  nearly  double  the 
period  which  we  found  necessary  with  the  i  in  3,000, 
might  have  been  more  satisfactory  But  we  were  deterred 
from  experimenting  by  old  experience  of  suppurations 
encountered  under  the  use  of  this  weaker  lotion,  doubtless 
used  in  insufficient  quantity.     Finding  that  with  the  i  in 

4—2 


7 


52  Cataract  Extraction 

3,000  we^  were  able  to  abolish  suppurations,  and  at  the 
same  time  almost  always  to  avoid  excessive  reaction, 
fears  for  our  statistics  made  us  rest  content.  >  ^ 

The  patient  is  placed  recumbent  beneath  a  j'ar  of  the 
lotion  furnished  with  rubber  tube  and  glass^hozzle.  An 
assistant  everts  the  upper  lid  and  depresses  the  lower, 
and  keeps  them  both  cDTTstantly  mt^ving  in  the  vertical 
direction,  while  an  attendant  directs  a  stream  of  fluid  on 
to  the  exposed  surfaces.  The  movement  of  the  lids  is  to 
ensure  penetration  of  the  antiseptic  to  the  furrows  and 
recesses,  more  particularly  of  the  upper  fornix. 

In  the  cases  where  it  is  intended  to  instil  adrenalin  the 
period  of  irrigation  should  be  very  slightly  prolonged, 
because  the  immediate  reaction  to  the  perchloride  is 
lessened  by  the  adrenalin.  The  reaction  is  delayed 
simply. 

Rather  more  lotion  is  used  also  in  cases  where  there 
has  been  lacrymal  obstruction,  whether  it  has  been 
treated  or  not  by  excision  of  the  sac* 

The  irrigation  usually  causes  some  smarting,  but  this 
gives  way  rapidly  to  the  cocain  instillation. 

Anaesthesia.  —  Cocain  is  instilled  several  times  at 
definite  intervals.  It  is  uged  in  solution  varying  from 
2  per  cent,  to  5  per  cent,  (fl  have  instilled  always  a  4  per 
cent,  solution  four  times.)  If  this  be  done  at  three  minutes' 
intervals,  the  eye  is  ready  for  operation  one  minute  after 
the  final  instillation — i.e.,  ten  minutes  after  the  first  instil- 
lation. / 

On  each  xrccasion  several3rops  are'tlsed,  for  though  little 
remains  in  the  conjunctival  sac,  the  trace  of  fluid  already  there 
has  to  be  displaced,  and  if  the  conjunctiva  be  thus  flushed  out, 

j  *  Plant  and  Zelewsky  {Klin.  M.  f.  A.,  1901,  S.  369)  have  shown 
/ //'that  after  extirpation  of  the  lacrymal  sac  bacteria  are  more  numerous 
,i',in  the  conjunctival  sac. 


Description  of  the  Operation  53 

the  cocain  solution  penetrates  to  the  fornices  undiluted  with 
tears.  The  assistant  should  watch  the  patient  in  the  intervals 
to  see  that  the  eyelids  are  kegt  closed,  to  prevent  drying  of  the 
corneal  surface  and  subsequent  exfoliation  of  epithelium. 
Landolt  uses  this  solution  five  times  during  iw^ty-five 
minutes.  Haah^^^iHihe  case  of  patients  with  little  self-control, 
and  in  cases  in  which  prolapse  of  vitreous  is  to  be  feared,  instils 
a  drop  of  3  to  5.  per  cent,  solution  every  three  minutes  for  half 
an  hour.  It  is  said  that,  in  spite  of  all  precautions,  such  frequent 
instillations  tend  to  cause  opacity  of  the  corneal  epithelium, 
and  encourage  subsequent  collapse  of  the  cornea.  Haab  uses 
the  drops  in  both  eyes,  *  to  guard  against  the  disturbing  acci- 
dent of  reflex  closure  of  the  lid,  in  case  a  drop  of  fluid  of  any 
kind  accidentally  gets  into  the  other  eye  during  the  operation.' 
With  both  eyes  thus  being  rendered  anaesthetic,  watchfulness 
is  more  essential,  to  prevent  opening  of  the  lids  in  the  intervals 
of  instillation. 

The  degree  of  anaesthesia  ordinarily  attained  by  cocain 
varies.  The  quantity  used  by  us  sometimes  sufficed  to  abolish 
pain ;  but  in  other  cases  the  pull  upon  the  iris  for  the 
iridectomy  was  painful,  and  some  patients  winced  a  little  even 
from  the  grip  of  the  fixation  forceps.  Possibly  the  earlier 
drops  may  have  been  often  washed  away  by  a  flow  of  tears, 
excited  by  the  perchloride  irrigation.  Roller  (New  York) 
Jnjects  cocain  subconjunctivally  for  cataract  extraction,  to 
make  the  operation  quite  painless. 

None  of  the  other  local  anaesthetics  which  have  been  tested 
in  eye  work — eucain,  holocain,  stovain,  alypin,  etc. — appear 
likely  to  displace  cocain.  The  blanching  effect  of  cocain  is 
useful  in  operations  with  a  conjunctival  flap,  especially  in  our 
work,  owing  to  the  hyperaemia  excited  by  the  perchloride 
douching.  Maynard  (Calcutta),  operating  with  a  small  con- 
junctival flap,  and  using  alypin,  found  it  advisable  to  add 
adrenalin  solution  to  control  bleeding. 

Of  late  years  many  ophthalmic  surgeons  have  utilized 
preparations  of  adrenal  extract  more  or  less  regularly  to 
enhance  the  effect  of  the  local  anaesthetic  and  to  lessen 
bleeding.     I  have  used  the  well  known  adrenalin  chloride 

*  'Operative  Ophthalmology,'  p.  128. 


54  Cataract  Extraction 

solution,  and  also  ophthalmic  discs  of  *  hemisine.'  The 
solution,  I  in  i,ooo,  unsterilized,*  was  not  mixed  with 
the  cocain  drops,  nor  instilled  alternately  with  them,  but 
was  used  only  before  the  cocain  period.  It  was  dropped 
into  the  eye  immediately  after  the  perchloride  irrigation, 
and  the  cocain  instillation  deferred  for  five  minutes.  In 
cases  where  much  perchloride  had  been  used,  and  where, 
in  consequence,  an  unusual  degree  of  hyperaemia  had  to 
be  combated,  a  second  instillation  was  made  two  and  a 
half  minutes  after  the  first.  This  aid  is  quite  necessary 
in  the  subconjunctival  extraction  of  Czermak,  and  almost 
so  in  operations  with  a  large  conjunctival  flap,  to  control 
haemorrhage.  It  is  of  great  value  also  in  nervous,  excitable 
patients.  The  docility  and  quietude  of  these  patients 
during  operation,  thus  rendered  certainly  painless,  are  in 
striking  contrast  with  their  uncertainty  and  unreasonable- 
ness under  cocain  alone.  It  is  thus  calculated  to  reduce 
the  number  of  vitreous  losses  from  spasmodic  closure  of 
the  lids,  and  is  indicated  where  vitreous  loss  is  especially 
to  be  feared,  as  in  high  myopia.  The  more  complete 
anaesthesia  may  be  useful  also  in  operating  upon  children 
by  linear  extraction.  And  for  eyes  still  congested  from  a 
glaucomatous  attack  (Chapter  VI),  and  especially  in 
excising  prolapsed  iris,  the  help  of  adrenalin  is  needed, 
since,  as  is  well  known,  cocain  alone  acts  imperfectly  in 
these  conditions.  In  some  of  these  latter  cases  a  third 
instillation  of  adrenalin  solution  was  made,  and  the 
intervals  between  the  cocain  instillations  prolonged,  so 
that  a  total  period  of  possibly  half  an  hour  was  thus 
occupied.  Even  thus  the  pull  upon  previously  congested 
iris  may  be  painful. 

*  To  avoid  frequent  opening  of  the  original  bottle  of  solution,  about 
enough  for  the  day's  supply  was  decanted  into  a  small  sterilized 
bottle  for  immediate  use. 


Description  of  the  Operation  55 

In  simple  extraction  there  are  especial  advantages 
derivable  from  the  combination  of  adrenalin  with  cocain, 
which  tend  to  reduce  greatly  the  liability  to  prolapse  of 
iris  (see  Chapter  IV), 

With  this  combination  a  faint  corneal  milkiness  is  occasion- 
ally noticeable  at  the  time  of  operation,  followed  next  day  by  a 
rough  surface  from  exfoliation  of  epithelium.  This,  in  spite  of 
watchfulness  during  the  instillation  and  frequent  moistening 
of  the  cornea  during  operation.  When  used  freely  upon  pre- 
viously congested  eyes,  whether  for  cataract  extraction  or 
excision  of  prolapse,  there  is  a  possibility  of  a  more  unpleasant 
after-effect.  In  a  case  of  acute  glaucoma  of  both  eyes,  in  which 
we  instilled  adrenalin  solution  three  times,  alternating  with 
the  cocain  drops  before  performing  iridectomy,  we  found  next 
day  both  pupils  and  irises  covered  with  a  layer  of  lymph.  This 
took  some  days  to  become  absorbed,  and  left  some  fine  posterior 
synechiae.  We  attributed  it  to  the  reaction  following  the 
adrenalin-constriction  of  blood-vessels  already  weakened  by  the 
acute  glaucoma. 

The  mouth-screen  or  respirator  shown  in  Fig.  39  is  simply  a 
'layer  of  flannel  stretched  over  a  wire  frame,  and  fitted  with 
elastic  loops  to  hang  over  the  ears.  It  is  sterilized  by  pro- 
longed soaking  in  sublimate  solution.  Gauze  veils  have  been 
largely  used,  covering  mouth  and  beard,  and  in  some  cases  the 
nose  also. 

INITIAL  STEPS. 

The  ten-minutes  cocain  period  being  ended,  the  patient 
must  be  lying  on  a  suitable  table  or  bed.  The  pillow  is 
protected  by  a  waterproof  sheet  covered  with  a  towel, 
and  another  towel  (preferably  sterilized)  covers  the 
patient's  head  and  forehead,  to  protect  the  surgeon's 
clothing  and  to  serve  as  a  clean  support  for  his  hands. 

In  addition  to  the  instrument  tray,  there  must  be  at 
hand  a  bowl  of  i  in  3,000  perchloride  lotion,  containing 
bits  of  sterilized  lint  or  absorbent  wool,  also  of  gauze  or 
muslin. 


Cataract  Extraction 

TH^^/idrgeon  takes  up  his  position  at  the  head  of  the 
patient,  the  assistant  at  the  same  side  as  the  eye  to  be 
operated  upon,  and  an  attendant  with  the  irrigator 
opposite  to  him. 

Expression     of    Meibomian     Secretion.  —  The    lid 

borders   are   squeezed   together,  with   their   conjunctival 

surfaces  in  contact,  between  the  surgeon's  left  forefinger 

placed  horizontally  on  the  UMfer  lid  and  his  right  thumb- 

I  nail  on  the  lower  lid  (Fig.  42).     ^ 


Portions  of  the  lids  are 


Fig.  42. — Expression  of  Meibomian  Secretion. 


thus  treated  successively  and  repeatedly  until  no  more 
fatty  matter  can  be  expressed  from  the  mouths  of  the 
Meibomian  glands.  As  it  appears  on  the  lid  margins,  the 
secretion  is  wiped  away  by  the  assistant  with  bits  of  lint 
from  the  bowl  of  sublimate  lotion.  At  the  same  time  the 
opportunity  may  be  taken  to  swab  the  edges  of  the 
lids,  as  a  final  cleansing. 

I     Unless  the  glands  are  well  emptied,  one  may  find  that 

during  the  operation  the  irrigating  fluid  used  for  moisten- 

IJing  the  eye  and  for  washing  out  the  chamber  is  very  apt 


A 


Description  of  the  Operation  57 

to  cover  the  globe  with  a  floatfng  iriciescent  scum,  or  with 
a  succession  of  small  fatty  particles,  which  cannot  be  com- 
pletely washed  awa)'  unless  the  speculum  be  removed  and 
the  squeezing  of  the  lids  be  repeated.  The  fatty  matter  is 
seen  to  ooze  from  the  mouths  of  the  glands  close  to  the 
arms  of  the  speculum,  where  the  latter  cross  the  lid 
borders. 

The  quantity  of  matter  which  can  be  expressed  from 

some  of  the  glands  is  remarkable,  especially  in  the  flaccid 

lids  of  some  old  people ;  and  it  varies  much  in  consistence 

and  colour,  occasionally  looking  like  pus.     There  can  be 

little   doubt   that,  in    some   cases   at   least,   it   is   highly 

desirable  to  prevent  this  material  from  entering  the  con- 

I  junctival  sac  during,  or  even  after,  operation.     I  smeared 

I  secretion  from  ten  unselected  lids  upon  Loffler's  serum, 

!    but  only  obtained  cultures  in  three  instances — once  white 

I  staphylococci  alone,  once  xerosis  bacilli  alone,  and  once 

[  I  the  two  organisms  together. 

Often  so  much  pressure  is  required  that  it  becomes  a 
little  painful.  But  patients  are  not  allowed  to  demonstrate 
by  groaning  or  drawing  in  their  breath  or  moving  their 
heads.  Otherwise  there  is  great  risk  of  their  presuming 
upon  the  licence  allowed  them,  giving  trouble  later  by 
attempting  to  close  their  lids,  with  dire  consequences. 
This  Meibomian  expression,  and  also  the  lid  manipula- 
tions now  to  be  described,  are  useful  as  a  test  of  the 
behaviour  to  be  expected  of  the  patient  during  the 
operation.  A  warning  of  the  need  for  special  care  is 
frequently  thus  obtained.  _/ 

If  perchloride  has  been  used  as  directed,  the  lids  are    ' 
now  everted  and  moved  freelj^upon  Mx:h  other  laterally, 
while  a  stream  of  physiological"~sadT  solution  is  directed 
upon  them  from  the  flask  by  the  attendant.     We  expect 
to  find  in  fairly  normal  conjunctivae,  in  response  to  the 


58  Cataract  Extraction 

irritative  and  coagulative  action  of  the  sublimate  used  for 
douching,  an  accumulation  of  mucus  in  the  fornices,  with 
perhaps  a  trace  of  shreddy  membrane  lying  over  the  tarsi. 
This  is  washed  away,  any  adherent  threads  being  detached 
with  a  bit  of  gauze  from  the  bowl  of  lotion  standing  near. 
The  curette  may  be  used  to  remove  particles  of  mucus 
lying  in  the  hollows  about  the  plica.  Already,  also,  we 
may  generally  detect  some  slight  swelling  of  the  lids — 
perhaps  only  a  barely  perceptible  fullness  as  compared 
with  the  lids  of  the  fellow  eye.  In  spite  of  this  sign  of 
reaction,  it  is  well  to  use  a  little  more  sublimate  now 
from  the  bowl  of  lotion,  squeezed  out  of  a  pledget  of  lint 
at  least  once.  The  lids  are  then  released,  and  the  remains 
of  the  lotion  washed  away  with  normal  saline  after  the 
insertion  of  the  speculum. 

When  too  much  of  the  antiseptic  has  already  been 
applied,  there  may  be  loose  pseudo-membranous  exudation 
covering  the  greater  part  of  the  upper  tarsus.  The  bulbar 
conjunctiva  towards  the  fornices  may  be  a  little  swollen, 
and  the  swelling  of  the  lids  will  be  more  noticeable,  with 
slight  injection  of  the  lid  borders.  Though  by  the  end  of 
the  operation  these  signs  will  have  become  slightly  more 
marked,  but  little  further  increase  need  be  anticipated 
later.* 

It  is  much  more  common  to  find  the  reaction  insuffi- 
cient ;  there  may  be  scarcely  any  mucus  secreted  at  all. 
Rather  more  lotion  must  then  be  used,  squeezed  out  of 
the  pledget  of  lint  perhaps  three  or  four  times.  In  con- 
junctivae diffusely  scarred  or  thickened,  roughened,  and 
indurated,  the  formation  of  mucus  is  always  very  scanty 
or  entirely  wanting.     Here  the  supplementary  perchloride 

*  Throughout  our  experience  the  conjunctival  lesions  known  to 
have  been  produced  by  the  perchloride — patchy  pseudo-membranous 
conjunctivitis  from  destruction  of  epithelium — could  be  counted  on 
the  fingers  of  one  hand. 


Description  of  the  Operation  59 

treatment  is  even  a  little  more  free,  being  continued  in 
the  case  of  the  chronically  thickened  palpebral  membranes 
till  a  faint  superficial  paleness  is  seen,  evidently  due  to 
change  in  the  superficial  epithelium.  In  the  diffusely 
scarred  conjunctivas  this  sign  is  not  commonly  obtained. 
(It  will  be  remembered  that  a  few  of  the  worst  conjunctivae 
we  had  to  deal  with  in  Bombay  had  already  had  two 
applications  of  the  perchloride,  the  first  being  at  the 
early  morning  inspection.  They  were  thus  treated  three 
times  in  all.  They  never  reacted  excessively,  and,  on 
the  other  hand,  we  had  reason  to  believe  the  treatment 
efficacious,  for  we  never  had  any  infective  after-troubles  in 
these  cases.)  In  any  case,  this  supplementary  douching 
is  much  shorter  than  that  carried  out  before  the  cocain 
instillation. 

Should  perchloride  irrigation  not  have  been  practised, 
the  surgeon  having  decided  in  favour  of  simple  mechanical 
cleansing,  this  is  now  carried  out.  This  is  preferably  by 
irrigation  with  warm  sterilized  normal  saline  solution, 
combined  with  careful  swabbing,  more  particularly  of  the 
palpebral  conjunctiva  and  of  the  fornices,  and  of  the 
recesses  about  the  plica.  For  the  retrotarsal  folds  a 
number  of  small  swabs  are  required,  mounted  on  glass 
rods  or  held  in  forceps.  Some  surgeons  use  simply  boiled 
water,  others  boric  acid  lotion,  or  some  weak  antiseptic 
solution,  such  as  mercuric  cyanide,  i  in  5,000,  or 
weaker. 

The  irrigator  attendant  is  required  for  the  one  instrument 
throughout  the  operation.  It  is  his  duty,  apart  from  the  execu- 
tion of  particular  orders,  to  prevent  drying  of  the  cornea.  He 
should  drop  a  little  fluid  upon  the  eye  in  most  of  the  intervals 
between  the  steps  of  the  operation ;  he  should  not  use  an 
unnecessarily  large  quantity,  flooding  the  conjunctival  sac. 
He  must  avoid  allowing  the  sterilized  nozzle  of  the  tube  to 
touch  the  surgeon's  fingers  at  any  time.     The  nozzle  there- 


6o  Cataract  Extraction 

fore  must,  as  a  rule,  be  kept  at  a  distance  of  2  or  3  inches  from 
the  eye.  He  must  be  careful  also  to  avoid  accidentally  spray- 
ing the  patient's  face  with  the  solution.  In  one  of  our  cases  a 
considerable  loss  of  vitreous  was  caused  by  reflex  closure  of 
the  lids  excited  in  this  way. 

The  speculum  is  then  inserted  between  the  lids. 

In  applying  the  speculum  it  is  held  with  its  arms  pressed 
together  in  the  right  hand  for  the  right  eye,  and  in  the  left 
hand  for  the  left  eye.  The  upper  lid  is  drawn  forward  by 
seizing  the  eyelashes  between  the  thumb  and  forefinger  of  the 
other  hand,  and  the  upper  bar  (or  plate)  of  the  speculum 
slipped  beneath  it.  This  lid  being  then  released,  the  lower  lid 
is  drawn  down,  and  the  other  arm  placed  in  position.  The 
spring  of  the  instrument  is  commonly  sufficient  to  separate  the 
lids  to  their  utmost.  Very  occasionally  the  arms  may  need  to  be 
pressed  further  apart  by  the  fingers,  or,  in  very  prominent 
eyes,  a  too  wide  separation  may  be  reduced  by  finger  pressure 
before  the  instrument  is  locked. 

If  at  any  time  after  the  making  of  the  incision  the  instrument 
has  been  removed,  in  its  re-insertion  the  upper  arm  is  again 
placed  in  position  first ;  but  during  its  insertion  the  lower  lid  is 
drawn  away  from  the  eye  by  the  finger  of  the  assistant,  lest  by 
contracting  on  the  globe  it  should  force  the  wound  open. 

In  thin  patients  the  weight  of  the  speculum  is  apt  to  draw 
the  lower  lid  back  so  much  that  the  end  of  the  arm  of  the 
speculum  (Clark's  model),  lying  in  front  of  the  lid  border, 
catches  behind  the  orbital  margin.  In  any  case  where  the 
arm  (or  end-plate)  of  the  speculum  is  seen  pressing  upon  the 
eye  it  should  be  elevated,  both  to  take  the  weight  of  the  instru- 
ment off  the  globe  and  to  make  room  for  the  fixation  forceps. 
This  is  done  by  a  forward  push  at  the  temporal  end  of  the 
instrument  with  the  little  finger  or  side  of  the  hand,  after  taking 
up  the  knife  in  readiness  to  make  the  section. 

Except  in  extraction  by  downward  section,  it  is  convenient 
to  retain  the  speculum  as  long  as  possible— ^'.e.,  till  the  final 
cleansing  (curetting)  of  the  conjunctiva.  But  since  it  gives  no 
control  over  the  action  of  the  peripheral  fibres  of  the  orbicularis 
muscle,  and  since  its .  presence  increases  the  tendency  to 
expulsion  of  the  contents  of  the  globe  on  contraction  of  the 


Description  of  the  Operation  6i 

muscle,  its  withdrawal  may  be  found  necessary  at  any  stage 
after  the  completion  of  the  incision.  Some  surgeons  always 
remove  it  then,  others  at  various  later  periods — after  any  one  of 
the  steps  of  the  operation. 

The  outer  lashes  of  the  upper  lid  are  cut  short  by 
curved  scissors,  beyond  the  point  where  the  arm  of  the 
speculum  crosses  the  lid  border.  This  is  only  omitted  if 
the  eyes  be  so  prominent  that  the  lashes  lie  out  of  the 
line  of  the  knife  when  in  position  for  the  corneal  section. 
It  is  obviously  important  that  no  portion  of  an  instrument 
shall  touch  the  lashes  before  entering  the  wound,  but  in 
this  connexion  removal  of  any  but  the  outer  lashes  of  the 
upper  lid  is  uncalled  for. 

The  eye  is  then  at  once  moistened  with  a  stream  of 
fluid  from  the  irrigator,  otherwise  it  is  extraordinary  how 
soon  the  corneal  surface  becomes  dry.  The  excess  of  fluid 
is  run  out  of  the  conjunctival  sac  by  momentarily  tilting 
the  head  to  the  side  ;  or,  if  necessary,  it  may  be  mopped 
up  at  the  outer  canthus  by  the  assistant  with  a  pencil  of 
moist  gauze  or  lint  taken  from  the  bowl  of  lotion. 

The  patient  must  look  downwards  to  expose  fully  the 
upper  corneal  circumference  in  the  palpebral  aperture. 
Very  prominent  eyes  scarcely  need  be  turned  down  at  all. 
Sunken  eyes  need  to  be  rolled  down  well ;  the  patient 
should  look  towards  one  of  his  hands  held  up  by  the 
assistant.  Sufficient  rotation  of  the  globe  may  be  im- 
possible owing  to  cicatricial  contraction  of  the  conjunc- 
tiva, the  retracted  fornices  being  fixed  by  the  speculum. 
In  such  cases  Czermak's  lower  subconjunctival  section 
(Chapter  IV)  should  replace  the  ordinary  one. 

It  is  well  that  instructions  to  the  patient  regarding  the 
position  of  his  eyes  should  be  given  by  the  assistant,  who 
stands  near  the  position  towards  which  the  eyes  have  to  be 
turned.     Nervous  patients,  especially  those  blind  in  both  eyes, 


62  Cataract  Extraction 

feel  a  natural  inclination  to  look  towards  the  person  who  issues 
the  commands.  They  are  often  able  to  respond  better  to  the 
assistant  who  has  trained  them  than  to  anyone  else.  No 
bystanders  are  to  be  permitted  to  add  instructions  or  remarks, 
and  the  patient  must  not  be  allowed  to  answer  by  word  of 
mouth  to  orders  given,  otherwise  he  is  apt  to  substitute  this  in 
some  degree  for  compliance  with  the  directions  given.  The 
orders  given  should  be  as  few  as  possible.  And  it  is  important 
to  avoid  making  the  patient  look  downwards  earlier  than 
necessary,  lest  the  patient's  stock  of  self-command  should 
become  exhausted,  and  early  relaxation  of  effort  should  lead  to 
an  upward  roll  of  the  eyes. 


THE  COMBINED  OPERATION. 

The  above  preliminary  measures  apply  to  all  the 
modifications  of  the  operation  for  cataract  extraction  by 
upper  section.  A  full  description  will  now  be  given  of 
each  step  of  the  '  combined '  flap  extraction — i.e.,  with  iri- 
dectomy. This  may  be  regarded  as  the  standard  method 
of  extraction,  since  in  many  cases  it  is  the  only  operation 
at  all  suitable,  and  is  performed  almost  exclusively  by 
many  surgeons,  and  is  especially  the  operation  for  begin- 
ners. After  the  incision  has  been  made,  a  piece  of  iris  is 
removed  and  the  lens  capsule  opened.  The  lens  is  then 
expelled  by  pressure,  its  capsule  being  left  behind.  Later, 
in  Chapter  IV,  each  step  of  the  operation  will  be  more  fully 
discussed  and  alternative  procedures  described,  more  parti- 
cularly *  simple  '  extraction,  without  iridectomy,  and  intra- 
capsular extraction.  Finally,  in  Chapter  VI  the  *  linear  ' 
extraction  of  soft  cataracts  will  be  described,  together  with 
measures  adapted  for  some  complicated  cataracts. 

THE  SECTION,  as  commonly  made  in  the  '  combined ' 
operation,  raises  a  flap  comprising  the  upper  two-fifths,  or 
rather  less,  of  the  cornea,  with  or  without  a  small  con- 
junctival addition  at  its  summit.     The  cutting  of  a  con- 


Description  of  the  Operation 


63 


junctival  flap  necessitates  a  slight  encroachment  into 
superficial  scleral  tissue  ;  otherwise  the  usual  incision  lies 
entirely  in  corneal  tissue,  and  at  the  surface  of  the  globe 
corresponds    exactly   with   the    sclero-corneal    boundary. 


Fig.   43. — SCLERO-CORNEAL   SECTION,  WITH    CONJUNCTIVAL   FLAP. 

In  Bombay  the  generally  unsatisfactory  or  doubtful  state 
of  the  conjunctiva,  indicating  the  need  for  an  effective 
covering  to  the  wound,  led  to  the  routine  inclusion  of  a 
somewhat   unusually   extensive   conjunctival   flap,    about 


Fig.  44.— Diagrammatic  Representation  of  Plane  of 
Incision. 

{a)  At  the  visible  corneal  margin,  and  (d)  behind  this,  cutting  into 
sclera  and  conjunctiva  (modified  from  Czermak,  '  Die  Augen.  Op.'). 

i'5  millimetres  long  at  the  suiiimit  of  the  arch,  and 
tapering  away  at  the  sides  of  the  wound.  This  involved 
the  addition  of  a  complete  narrow  rim  of  superficial 
sclerotic  to  the  boundary  of  the  corneal  flap  (Figs.  43  and 


64  Cataract  Extraction 

44).  Feeling  that  this  section  might  be  more  generally 
adopted  with  advantage,  the  following  description  is  based 
primarily  upon  it.  It  is  to  be  understood  that  the  employ- 
ment of  a  fairly  complete  conjunctival  flap  necessitates 
some  provision  for  preventing  or  dealing  with  haemorrhage 
into  the  anterior  chamber — either  the  preliminary  instilla- 
tion of  adrenalin  solution,  or  irrigation  of  the  chamber,  or 
both.  In  Bombay,  for  the  greater  part  of  my  time  there, 
we  relied  entirely  upon  irrigation,  but  quite  lately  we 
made  use  of  adrenalin  more  and  more. 

In  defining  the  course  of  the  incision,  it  is  well  to  bear  in 
mind  that  there  is  considerable  variation  in  the  boundary 
between  cornea  and  sclera  above.  In  some  eyes  the  degree  of 
overlapping  of  the  deeper  corneal  margin  by  superficial  scleral 


Fig.  45.— Overlapping  Sclera  above. 

tissue  is — so  far  as  one  can  tell  clinically — precisely  the  same 
above  as  at  the  sides  and  below.  In  other  eyes  a  thin  layer  of 
superficial  sclerotic,  with  its  covering  of  loose  conjunctiva, 
comes  forward  over  the  cornea  to  a  distinctly  greater  distance 
above  than  elsewhere.  In  the  former  case  when  cutting 
upwards  in  a  plane  parallel  to  the  iris,  an  incision  begun  at  the 
margin  of  clear  cornea  remains  so;  whereas  in  other  eyes 
the  knife,  in  making  such  a  section,  cuts  upwards  through  some 
superficial  scleral  fibres  and  through  loose  conjunctiva. 

The  overlying  strip  of  scleral  and  conjunctival  tissue  above 
is  too  thin  to  present  clinically  the  opaque,  white  appearance 
of  the  neighbouring  sclerotic.  It  is  seen  as  a  narrow,  greyish- 
white  crescent,  with  a  fairly  well  defined  upper  boundary  (see 
Fig.  45).  In  a  few  of  the  eyes  met  with  in  India  bearing 
traces  of  old  trachoma,  this  uppermost  deep  corneal  boundary 
is  the  only  recognizable  division  remaining  between  cornea 
and  sclerotic.  The  limbus  merges  into  the  marginal  opacity 
left  by  old  pannus.     This,  however,  matters  little  with  regard 


Description  of  the  Operation  65 

to  our  cataract  incision,  for  one  regulates  the  direction  of  the 
knife  edge  about  the  summit  of  the  arch  entirely  by  the  con- 
junctival flap,  according  to  whether  it  appears  to  need  to 
be  lengthened  or  shortened  in  individual  cases. 

Stellwag  found  the  vertical  measurement  of  the  front  surface 
of  the  cornea  to  vary  from  9*5  millimetres  to  12-5  millimetres, 
whereas  the  horizontal  measurement  varied  only  from  11*9 
millimetres  to  12-6  millimetres,and  the  boundary  of  the  posterior 
surface  was  practically  circular. 

Most  surgeons  of  experience,  having  taken  up  the 
position  already  mentioned,  behind  the  patient's  head, 
cut  with  the  right  hand  upon  the  right  eye  and  with  the 
left  hand  upon  the  left  eye,  the  other  hand  being  occupied 
in  fixing  the  globe.  This  plan  of  operation  is  assumed 
throughout  the  following  lines,  but  it  is  not  that  best 
suited  to  the  average  right-handed  beginner.  The  latter 
should  use  his  right  hand  for  cutting.  For  the  incision 
in  the  left  eye  he  must  stand  by  the  patient's  left 
side.* 

The  Graefe  knife,  with  blade  2  millimetres  broad,  is 
seized  about  the  middle  of  the  handle  between  the  thumb 
and  the  index  and  middle  fingers,  much  as  one  lifts  a  tea- 
spoon. The  cutting  edge  is  directed  towards  one,  and 
the  back  of  the  handle  rests  in  the  groove  between  the 
nail  and  tip  of  the  middle  finger.  The  other  hand,  hold- 
ing the  fixation  forceps,  obtains  firm  support  across  the 
patient's  nose.  The  conjunctiva  is  gripped  by  the  forceps 
below  the  middle  of  the  cornea.  A  large  hold  is  taken  to 
lessen  the  chance  of  tearing  ;  and  it  is  as  close  to  the 
cornea  as  possible,  because  at  a  little  distance  away  from 
the  cornea  the  inelastic  senile  mucous  membrane  may  be 
too  loose  and  mobile  to  serve  in  restraining  the  move- 

*  This  position  is  for  the  making  of  the  incision  only,  and  is 
changed  immediately  afterwards.  The  surgeon  displaces  the  assis- 
tant, whose  services  are  for  the  moment  not  required. 

5 


66 


Cataract  Extraction 


The  degree  of  control  secured  should 


ments  of  the  eye 
be  tested  by  a  lateral  pull  with  the  forceps ;  it  is  never 
absolute.  The  object  of  fixation  is  merely  to  retain  the 
globe  in  the  position  which  it  has  taken  up.     The  eye  is 


Fig.  46.— The  Puncture. 

Note  the  wrist  resting  against  the  patient's  head  ;  also  the  mode  of 
holding  the  knife. 

not  to  be  pulled  into  position  by  the  forceps,  though 
during  the  cutting  the  grip  of  the  forceps  may  have  to 
resist  a  fairly  strong  upward  pull  of  the  eye. 

The  cutting  hand  is  steadied  by  resting  the  tip  of  the 


Description  of  the  Operation  67 

little  finger  against  the  patient's  temple,  with  the  fingers 
more  or  less  in  contact  with  one  another.  I  can  recom- 
mend to  nearly  all  beginners,  and  to  many  experienced 
operators,  additional  support  to  control  tremor  of  the 
hand.  Free  movement  at  the  wrist  is  not  required.  The 
wrist  is  therefore  carried  inwards  to  rest  firmly  against  the 
patient's  head.  The  hand  is  thereby  bent  back  at  the 
wrist  joint,  and  the  point  of  the  knife  thrown  somewhat 
downwards.  The  point,  thus  directed  inwards  and  a  little 
downwards*  (Fig.  46),  is  inserted  through  conjunctiva  and 
sclera  |  to  i  millimetre  from  the  corneal  margin,  rather 
more  than  i  millimetre  above  the  outer  end  of  the  hori- 
zontal corneal  meridian.  In  eyes  with  shallow  anterior 
chamber  the  point  must  be  directed  a  little  forward  to 
escape  cutting  the  forward-arching  iris,  and  therefore 
the  puncture  is  begun  a  little  farther  from  the  cornea  (fully 
I  millimetre).  But  in  ordinary  cases  the  blade  lies  exactly 
in  the  transverse  plane.  The  edge  of  the  knife  is  directed 
straight  upwards,  in  a  line  exactly  parallel  with  the  corneal 
margin,  which  serves  to  guide  the  knife.  The  sunken  eyes 
of  some  emaciated  patients,  and  eyes  with  palpebral 
aperture  contracted  by  old  trachoma,  may  have  to  be 
rotated  somewhat  inwards  by  the  fixation  forceps,  to 
enable  the  blade  to  be  placed  correctly  with  regard  to  the 
eye,  and  at  the  same  time  to  lie  quite  clear  of  the  outer 
end  of  the  upper  lid  border.  The  penetration  of  the 
tissues  is  made  with  deliberation,  and  the  point  of  the 
knife  swung  up  to  the  horizontal  direction  as  soon  as  it  is 
well  within  the  anterior  chamber.     That  the  blade  lies  in 

*  Formerly,  when  stress  was  laid  upon  the  advantage  of  a  small 
linear  incision  in  lessening  the  hability  to  suppuration  of  the  wound, 
it  was  held  to  be  correct  to  point  the  knife  well  downwards  in  making 
the  puncture,  in  order  that  the  wound  should  be  as  large  as  possible 
at  the  deep  surface  of  the  cornea.  With  the  comparatively  large 
section  made  nowadays  this  point  is  of  less  importance. 

5—2 


68  Cataract  Extraction 

the  anterior  chamber  is  shown  by  its  bright  appearance 
and  by  its  mobility. 

If  the  anterior  chamber  happens  to  be  very  shallow,  the 
point  of  the  knife  in  passing  slowly  inwards  has  to  be 
guided  a  little  forward  over  the  bulging  iris  ;  and,  finally, 
in  attaining  the  transverse  plane,  which  it  must  do  to 
reach  the  site  of  counter-puncture,  the  blade  may  have  to 
press  against  the  iris,  indenting  it.  In  such  a  case  the 
swing  of  the  blade  may  tend  to  cause  a  slight  leakage  of 
aqueous  through  the  puncture. 

Eyes  which  have  been  pulled  inwards  by  the  forceps,  as 
above,  are  allowed  to  roll  outwards  again — at  least,  partly. 
This  movement  of  the  globe,  while  the  knife  is  held 
stationary,  takes  the  place  of  a  portion  of  the  movement 
of  the  blade  ordinarily  required  as  it  crosses  the  chamber. 

The  point  engages  in  the  posterior  surface  of  the  cornea 
at  the  nasal  side  about  ^  millimetre  before  its  disappear- 
ance behind  the  scleral  boundary.  This  brings  the  knife 
to  the  surface  barely  within  the  sclerotic,  and  not  at  the 
greater  distance  from  the  cornea*  which  one  might  antici- 
pate. The  site  of  this  counter-puncture  must  be  selected 
carefully,  and  corrected,  if  necessary,  more  than  once  by 
disengaging  the  point ;  but  there  must  be  no  trace  of 
hesitation  on  the  completion  of  the  counter-puncture,  lest 
the  aqueous  begin  to  flow  away.  The  knife  must  at  once 
travel  upwards  with  a  steady,  even,  inward  thrust,  cutting 
equally  on  both  sides  of  the  cornea,  to  bring  the  blade  well 
up  in  front  of  the  iris,  before  the  chamber  can  become 
emptied  of  fluid.  Usually  almost  the  whole  of  the  blade 
is  utilized  in  this  first  stroke  ;  but  in  operating  upon  eyes 
either  insufficiently  turned  downwards  or  purposely  still 

*  The  encroachment  upon  scleral  tissue  needs  to  be  rather  less  at 
the  inner  end  than  at  the  outer  end  of  the  section,  owing  to  the  fact 
that  the  knife  thrusting  inwards  tends  to  slip  under  the  conjunctiva  at 
the  inner  side  of  the  globe. 


Description  of  the  Operation  69 

rotated  a  little  inwards  (as  above),  the  movement  may  be 
ended  earlier  by  the  arrival  of  the  knife-point  at  the  car- 
uncle or  neighbouring  upper  lid  border.  In  other  cases 
the  point  of  the  knife  may  possibly  reach  the  side  of  the 
nose.  A  prick  anywhere  is  likely  to  make  the  patient 
wince,  and  attempt  to  close  his  eyes,  and  even  possibly 
move  his  head. 

Other  reasons  for  somewhat  early  arrest  of  the  inward 
stroke  may  be  met  with  occasionally  :  (i)  a  tendency  for 
the  outer  part  of  the  section  to  become  misplaced  a  little 
forward,  so  as  to  lie  entirely  within  the  cornea  ;  (2)  the 


Fig.  47. — Section  in  the  Plane  of  the  Knife,  showing  the 
End  of  the  Inward  Thrust. 

occurrence  of  prolapse  of  the  iris  through  the  inner  portion 
of  the  wound,  or  a  tendency  thereto. 

When  not  thus  prematurely  ended,  the  one  thrust  should 
suffice  to  bring  the  edge  of  the  knife  to  the  summit  of  the 
anterior  chamber.^  Yet  still  a  good  deal  of  tissue 
remains  to  be  cut  (see  Fig.  47),  nearly  always  more  in  our 
operations  than  can  be  cut  easily  in  a  single  reverse 
movement  of  the  knife. 

More  or  less  aqueous  leaks  away  as  the  knife  passes 

upwards,  yet  still  a  moderate  quantity  of  fluid  usually 

remains  in  the  chamber  after  the  completion  of  the  inward 

thrust,  when  the  latter  is  correctly  made.     Early  loss  of 

aqueous,  in  so  far  as  it  depends  upon  faulty  incision,  is  due 

less  to  slowness  in  cutting  than  to  alteration  in  the  plane 

of  the  blade.     Any  slight  twist  of  the  blade,  required  as 

*  It  must  be  confessed  that  in  our  Bombay  work,  with  knives  not  as 
sharp  as  they  might  have  been,  in  the  majority  of  cases  less  than  this 
w  as  accomplished  by  the  one  stroke  of  the  knife. 


70  Cataract  Extraction 

soon  as  one  notices  the  slightest  tendency  to  departure  from 
the  planned  line  of  incision,  of  necessity  prises  the  wound 
open  a  little  and  allows  some  fluid  to  escape.  Other 
occasional  sources  of  premature  leakage,  in  addition  to 
the  sloping  sclero-corneal  puncture  necessitated  by  a 
shallow  chamber,  already  alluded  to,  are :  (i)  uneven 
faltering  tension  on  the  cutting  edge,  due  possibly  to 
movement  or  attempted  movement  of  the  eye,  or  to  spasm 
of  the  lids,  or  to  tearing  of  the  conjunctiva  by  the  forceps ; 
and  (2)  partial  withdrawal  of  the  knife  for  any  particular 
reason  (see  below).  A  rather  quick  stroke  is  advisable  in 
eyes  with  shallow  chamber,  and  whenever  the  aqueous  is 
seen  to  be  flowing. 

In  the  brief  rest  which  follows  the  first  long  thrust  the 
opportunity  is  taken  to  note  (i)  the  condition,  and  (2)  the 
direction  of  the  knife.  Possibly  some  portion  of  the  blade 
may  have  already  touched  the  stumps  of  the  cut  eyelashes, 
or  the  upper  lid  border  at  either  end.  Or  some  rotation 
of  the  eyeball  by  the  forceps,  carrying  the  knife  with  it, 
may  be  advisable  to  remove  the  knife  from  risk  of  such 
contact  during  the  completion  of  the  section.  This  soiling 
of  the  blade*  is  frequent  in  operating  on  sunken  eyes  im- 
perfectly rotated  downwards,  and  it  may  be  quite  un- 
avoidable in  cases  where  the  palpebral  aperture  is  much 

*  Earlier  fouling  of  the  knife  may  be  caused  by  sudden  spasm  of 
the  orbicularis,  bringing  the  outer  part  of  the  upper  lid  border  into 
contact  with  the  blade,  in  spite  of  the  speculum.  The  contact  may 
be  only  with  the  under  surface  of  the  knife,  where  one  cannot  see  the 
soiled  patch.  If  o^ie  has  reason  to  suspect  that  this  has  taken  place, 
it  is  better  to  withdraw  the  instrument  than  to  risk  infection  of  the 
wound.  I  remember  doing  this  on  two  occasions  only.  Once,  when 
the  puncture  only  had  been  made,  the  cleansed  blade  was  reinserted 
satisfactorily  and  the  operation  completed.  On  the  other  occasion 
the  counter-puncture  had  also  been  made,  and  the  patient  was  nervous 
and  unreliable,  so  the  eye  was  bandaged  up  and  the  operation  post- 
poned. 


Description  of  the  Operation  7.1 

contracted*  from  old  trachoma.  And  yet  one  dare  not 
allow  any  soiled  portion  of  the  instrument  to  enter  the 
wound.  Where  there  is  no  difficulty  of  this  kind,  the 
section  is  completed  by  leisurely  to-and-fro  sweeps  of  the 
knife.  But  soiling  of  the  blade  at  one  or  both  ends  may 
leave  very  little  of  the  cutting  edge  available,  and  thus 
may  shorten  the  movements  very  much  indeed.  Then  a 
most  helpful  practice  is  to  combine  a  rocking  t  motion  with 
the  sawing  action  of  the  knife.  The  section  can  be  finished 
by  very  short  thrusts  with  the  knife  pointing  upwards  as 
well  as  inwards,  and  withdrawals  upwards  and  outwards 
(the  knife  pointing  downward  and  in).  Unless  the  surgeon 
be  keenly  alert  with  respect  to  this  matter,  infection  may 
readily  be  carried  from  the  lid  margin  into  the  wound, 
unsuspected. 

There  should  be  no  hurry  in  completing  the  incision. 
During  the  sawing  movements  attention  is  directed  to  the 
outlining  of  the  conjunctival  flap  at  either  side  (see  below), 
and  this  determines  any  slight  forward  or  backward 
twist  of  the  knife  which  may  be  necessary.  The  edge 
of  the  knife  frequently  has  to  be  turned  somewhat  forward 
to  follow  the  corneal  margin  above,  as  the  wound  tends  to 
open.  The  blade  at  once  slips  upwards  under  the  loose 
conjunctiva  as  soon  as  it  gets  through  the  firm  sclero- 

*  Not  only  is  the  aperture  small  in  these  cases,  but  full  rotation  of 
the  globe  downwards  frequently  impossible,  owing  to  anchoring  of  the 
eyeball  by  retraction  of  the  fornices.  In  five  marked  examples  of  this 
condition  I  had  to  divide  the  outer  canthus  with  scissors  (at  the  time 
of  the  cataract  operation)  to  obtain  room  for  the  play  of  the  knife. 
Nowadays  I  should  always  operate  upon  such  eyes  by  Czermak's 
subconjunctival  section,  with  scissors. 

t  This  rocking  action  of  the  knife  tends  to  be  added  on  to  the  to- 
and-fro  movements  without  intention  if  the  instrument  be  quite  loosely 
held.  I  have  frequently  combined  it  when  not  really  necessary, 
because  with  the  anterior  chamber  empty  it  appears  to  complete  the 
section  with  less  rubbing  of  the  iris  than  by  simple  transverse  move- 
ments. 


72 


Cataract  Extraction 


corneal  tissue  (see  Fig.  48).  If  allowed  to  come  through 
with  a  jerk,  the  patient  may  be  startled  and  try  to  close 
the  lids.     To  cut  through  the  conjunctiva  above,  the  knife 


Fig.  48. — CoMPLEiioN  of  the  Deep  Incision. 

The  knife  edge  must  now  be  turned  forward.  The  conjunctival  flap 
will  be  larger  than  usual.  (This  is  the  same  patient  as  shown  in 
Fig.  46.  Note  the  changed  position  of  the  hand.  The  palm  is  now 
partly  seen.) 

edge  is  turned  forward  at  the  selected  distance  above  the 
cornea. 

Only  with  a  keen  knife  can  due  gentleness  be  assured 
in    cutting.     Fig.    49    shows    the   wrinkling    and    slight 


Description  of  the  Operation  'jt, 

distortion  of  the  cornea,  with  displacement  and  elongation 
of  the  pupil,  produced  in  some  eyes  by  the  slightest  drag 
on  the  knife.  From  this  it  will  readily  be  seen  how  the 
first  reversal  of  the  movement  of  the  blade,  altering  the 
direction  of  the  folds  of  the  cornea,  is  commonly  accom- 


jL^ 

^u|iii|^BVk  lil^E^                    '-K^M^^^^H 

^K^'- m  ^                    jflB 

^^^H'      Mj^^mt^m     t                        '^'  v.^^^^^^^^H^H 

^^■^        -.1 

i 

Km.     -   « 

m 

Jcw>^ 

t    fM 

M^  Wp 

■HS|^\^ 

V^v  B->^      .jj^^  - 

Fig.  49.— Sawing  Movemp:nt  of  the  Knife. 
Pull. 


Outward 


panied  by  a  small  gush  of  fluid  from  the  anterior  chamber. 
This  occurs  even  though  the  pressure  upon  the  edge  of 
the  knife  be  evenly  maintained  throughout,  as  it  should 
be.  The  photograph  also  helps  one  to  realize  how  the 
pull  of  a  blunt  knife,  distorting  all  the  neighbouring 
structures,  may  stretch  and  even  rupture  the  underlying 


74  Cataract  Extraction 

zonule.*  This  risk  of  tearing  the  zonule  still  exists  during 
the  cutting  of  a  large  conjunctival  flap.  A  broad  strip  of 
loose  elastic  membrane,  such  as  is  seen  in  Fig.  48,  is  by 
no  means  easily  divided  unless  the  knife  be  very  sharp.t 
Several  to-and-fro  movements  of  the  blade  may  be  needed, 
during  which  the  deep  wound  is  pulled  open.  Blood  from 
the  episcleral  vessels  thus  finds  its  way  into  the  anterior 
chamber.!  This  occurred  especially  often  in  our  Bombay 
work,  because  until  lately  adrenalin  was  never  used,  and 
an   extensive   flap   (sometimes    completely   covering    the 

*  An  accident  possibly  signalized  at  once  by  partial  dislocation  of 
the  lens  and  perhaps  escape  of  vitreous,  but  possibly  on  the  other 
hand  passing  unrecognized  at  the  time,  and  giving  rise  to  loss  of 
vitreous  later  when  pressure  is  put  upon  the  eye  to  expel  the  lens. 
Twice  in  children  and  once  in  a  woman  of  twenty  years,  among  our 
operations,  the  zonule  gave  way,  and  escape  of  fluid  vitreous  occurred 
on  completion  of  the  section.  (Only  two  of  these  operations,  however, 
were  flap  extractions.  The  third  was  a  linear  extraction,  the  incision 
being  made  with  a  triangular  keratome.)  Particular  care  and  gentleness 
are  demanded  to  avoid  causing  loss  of  vitreous  in  making  the  incision 
for  tremulous  or  dislocated  lenses,  also  in  congested  glaucomatous 
eyes,  both  because  of  the  vitreous  tension,  and  because  of  the  pain 
and  consequent  spasm  of  the  lids  likely  to  be  produced  by  the  knife 
rubbing  upon  the  iris.  Danger  is  also  experienced  in  non-glauco- 
matous  eyes  with  vitreous  tension. 

t  One  dare  not  pull  much  upon  the  conjunctiva.  Repeated  light 
sawing  movements  are  effective,  though  their  repetition  may  prove  a 
little  tedious.  In  one  of  our  operations  the  drag  of  a  rather  blunt 
knife  upon  the  conjunctiva  appeared  to  be  partly  responsible  for  loss 
of  sight  in  the  eye.  It  was  a  case  of  black  cataract  in  a  highly  myopic 
eye.  While  a  large  conjunctival  flap  was  being  cut  the  lens  became  a 
I'ttle  displaced  upwards,  so  that  its  equator  presented  in  the  wound. 
Though  this  was  probably  due  to  fundus  haemorrhage,  it  appeared 
quite  possible  that  the  pull  on  the  conjunctiva  was  partly  responsible 
for  the  haemorrhage.  The  lens  was  delivered  by  a  touch  with  the 
cystitome,  and  was  immediately  followed  by  vitreous.  Next  day 
the  wound  was  found  distended  and  the  eyeball  filled  with  blood- 
clot. 

X  The  entry  of  the  blood  is  due  to  the  forward  pull  of  the  knife. 
This  is  shown  by  the  fact  that  the  chamber  may  be  momentarily 
emptied  by  turning  the  knife  edge  upwards,  while  the  chamber  refills 
as  soon  as  the  cutting  of  the  flap  is  resumed. 


Description  of  the  Operation  75 

wound)  was  frequently  cut  in  a  conjunctiva  congested  by 
exceptionally  free  perchloride  douching,  both  of  these 
precautions — the  conjunctival  covering  and  the  free  per- 
chloride treatment— being  combined  to  guard  against  the 
one  danger,  infection  from  an  unhealthy  conjunctiva.  By 
the  time  the  flap  has  been  cut,  the  knife  exchanged  for  the 
irrigator  nozzle,  and  the  latter  introduced  into  the  wound, 
the  blood  in  the  chamber  may  have  partly  clotted  and 
become  adherent  at  one  or  more  points  to  the  iris  firmly 
enough  to  defy  attempts  at  complete  removal  by  irrigation. 
(The  clot  is  usually,  however,  partly  expelled  later  with 
the  lens.)  Further  haemorrhage  into  the  chamber  may  be 
prevented  by  turning  the  conjunctival  flap  down  over  the 
cornea,  except  in  cases  where  the  flap  forms  a  complete 
covering.  The  lower  portions  of  a  complete  flap,  cover- 
ing the  sides  of  the  wound,  serve  to  direct  the  blood 
inwards. 

During  the  earlier  part  of  the  cutting  the  surgeon's 
mind  is  fully  occupied  with  the  incision.  As  soon  as  he 
has  time  to  notice  the  position  of  his  hand,  he  will  find 
that  it  has  changed  slightly  from  the  position  above 
described  and  shown  in  Fig.  45.  The  wrist  has  straightened 
a  little  and  rotated,  turning  the  palm  of  the  hand  more  to 
the  front  (Figs.  48  and  49),  and  bringing  its  inner  border 
close  to  the  patient's  head.  The  inner  border  of  the 
hand — or  of  the  little  finger,  if  the  patient's  head  be 
small  and  round — may  now  be  pressed  firmly  against  the 
head  for  support.  This  does  not  at  all  restrict  the  neces- 
sary movements  of  the  knife,  which  are  amply  provided 
for  by  movements  of  the  fingers,  with  slight  pronation 
and  supination  at  the  wrist. 

The  above  general  description  now  needs  amplifying  by 
the   consideration    of    slight   voluntary   and    involuntary 


76  Cataract  Extraction 

variations  of  technique,  and  by  the  recognition  of  occa- 
sional difficulties. 

The  right-handed  beginner  should  be  in  no  hurry  to  cut 
with  the  left  hand  in  operating  on  the  left  eye,  and  unless 
he  is  likely  to  operate  much  will  be  consulting  his  patients' 
interests  by  not  acquiring  the  habit.  Many  experienced 
operators  are  content  to  cut  always  with  the  right  hand. 
Most  men  will  find  that  a  very  considerable  expenditure 
*  of  time  in  training  and  exercises  will  be  necessary,  apart 
from  actually  operating,  to  enable  them  to  cut  as  ac- 
curately and  easily  with  the  left  hand  as  the  right.  If 
one  is  prepared  to  give  up  the  necessary  time  to  the 
training  it  is  doubtless  well  to  use  the  left  hand,  for  one 
has  more  natural  and  easy  control  over  one's  fingers  in 
cutting  towards  one  than  away  from  one.  But  for  myself, 
I  must  confess  to  a  slight  remaining  clumsiness  in  using 
the  left  hand,  revealed  in  results  mainly  by  a  larger  pro- 
portion of  irises  cut  by  the  knife  in  the  left  eye  than  in 
the  right.  In  using  the  right  hand  upon  the  left  eye  the 
wrist  is  unsupported. 

Fixation. — The  pull  of  the  forceps  resisting  the  inward 
push  of  the  knife  sometimes  raises  a  fold  of  conjunctiva 
covering  the  nasal  margin  of  the  cornea.  This  interferes 
with  the  accurate  locating  of  the  counter-puncture,  and  it 
also  directs  the  knife-point  far  under  the  loose  conjunctiva. 
The  grip  of  the  forceps  may  be  momentarily  released 
to  enable  one  to  see  the  point  of  the  knife  as  it  enters  the 
posterior  surface  of  the  cornea,  or  a  fresh  hold  may  be 
taken  farther  outwards  below  the  cornea. 

Where  the  fornices  are  moderately  retracted  by  scarring, 
the  ocular  conjunctiva  may  be  rendered  so  tense  by  the 
speculum  as  to  be  difficult  to  seize  by  the  forceps  below 
the  cornea.  A  much  stretched  conjunctiva  is  very  liable 
to  be  torn  by  the  forceps  while  the  section  is  being  made. 


Description  of  the  Operation  Tj 

Other  causes  of  tearing  are — (i)  straining  of  the  globe 
upwards ;  (2)  the  use  of  forceps  with  too  few  or  too  long 
teeth  ;  and  (3)  the  brittle  texture  of  some  senile  mucous 
membranes.  One  must  finish  the  operation  as  best  one 
can.  Usually  a  fairly  effective  hold  can  be  got  elsewhere. 
But  if  the  tear  be  a  large  one  and  take  place  early,  and 
the  eye  perhaps  unsteady,  it  may  be  very  difficult  to 
complete  the  incision  without  soiling  the  knife  on  the  lid 
margin.  The  patient's  co-operation  in  turning  the  globe 
downwards  is  essential  for  the  correct  use  of  the  knife. 
How'ever,  the  worst  that  has  happened  in  our  practice 
from  this  trouble  has  been  the  completion  of  the  section 
by  turning  the  knife  edge  forwards,  and  thus  sacrificing 
the  conjunctival  flap.  We  have  never  used  other  instru- 
ments to  replace  the  forceps,  such  as  Pamard's  spear,  or 
other  forms  of  double  hooks,  nor  have  we  attempted  to 
seize  the  internal  rectus  tendon,  nor  have  we  practised 
fixation  with  a  broad  conjunctival  suture.  Speaking 
generally,  frequent  tearing  of  the  membrane  by  the  forceps 
may  be  taken  as  ar>  indication  of  insufficient  training  of 
the  patients. 

During  the  progress  of  the  section,  the  beginner,  with 
his  attention  wholly  engrossed  in  the  incision,  may  find 
that  he  is  unconsciously  pressing  upon  the  globe  with  the 
forceps,  forcing  out  aqueous  and  perhaps  iris*  through  the 
wound.  To  avoid  the  liability  to  this  mistake,  it  is  suffi- 
cient to  obtain  a  firm  support  for  the  hand,  and  to  make 
sure  that  a  slight  forward  pull  upon  the  eyeball  is  being 
maintained  with  the  forceps  before  beginning  the  in- 
cision. 

The  s,ize  of  the  section  may  frequently  be  reduced  in 
combined  extraction.    A  corneal  flap  3  millimetres  high, 

*  Possibly  also  vitreous  on  the  completion  of  the  section  if  the 
pressure  be  not  relieved. 


78  Cataract  Extraction 

or  slightly  more,  including  about  one-third  of  the  corneal 
circumference,  suffices  for  the  easy  exit  of  lenses  with 
fully  ripe  soft  cortex.  In  dealing  with  a  Morgagnian 
cataract,  supposing  for  any  reason,  such  as  the  presence 
of  capsular  opacity,  combined  extraction  is  decided 
upon  beforehand,*  an  even  smaller  incision  is  ample, 
and  perhaps  preferable,  for  the  passage  of  the  smaller 
nucleus.  The  full-sized  incision  is  needed  for  lenses  with 
firm  cortex  and  dark  (and  probably,  therefore,  large) 
nuclei,  and  for  all  unripe  cataracts. 

No  increase  in  size  of  the  flap  beyond  two-fifths  of  the 
corneal  circumference  can  be  of  any  service  in  combined 
extraction.  The  base  line  of  this  section  has  practically 
attained  the  maximum,  and  the  height  of  the  flap  is  sufficient 
to  permit  of  wide  opening  of  the  wound.  And  there  is  not  the 
pupillary  reason  for  a  low  base  line,  which  applies  in  the  simple 
operation  (Chapter  IV).  One  is  inclined  in  combined  extrac- 
tion often  to  make  the  opening  slightly  larger  than  is  really 
required,  perhaps  a  little  from  the  force  of  habit,  if  one 
operates  frequently  by  'simple'  extraction,  and  still  more  from 
the  general  feeling  that  the  evils  of  too  small  an  incision  are 
decidedly  greater  than  those  of  an  unnecessarily  large  one. 

It  is  held  that  an  incision  including  one-third  of  the  corneal 
circumference  is  sufficient  for  the  combined  operation  in 
patients  under  forty-five  years,  and  that  any  increase  beyond 
the  actual  needs  of  the  case  is  to  be  avoided,  because  it  pre- 
disposes to  subsequent  incarceration  or  prolapse  of  iris  in  the 
angles  of  the  wound.  For  the  iridectomy  protects  only  a  limited 
central  portion  of  the  incision  from  iris  entanglement.  And 
the  sphincter  of  the  pupil,  considerably  disabled  by  the 
iridectomy,  is  less  able  to  retain  the  iris  within  a  large  wound 
than  in  simple  extraction.  It  might  be  added  that  accidental 
reopening  of  the  wound  is  more  likely  with  a  large  section,  but 
such  reopening  applies  chiefly  to  the  central  part — viz.,  that 
guarded  by  the  coloboma. 

The  drawbacks  of  too  small  a  section  are  more  obvious. 
And    the    enlargement    of    the    incision    with    blunt-pointed 

*  Simple  extraction  is  generally  preferable  for  these  lenses. 


Description  of  the  Operation  79 

'  secondary '  knife,  or  preferably  with  scissors  {e.g.,  by  Stevens' 
tenotomy  scissors),  though  a  little  troublesome,  is  entirely 
preferable  to  squeezing  a  bulky  hard  lens  through  too  small  an 
opening,  bruising  the  iris  and  the  lips  of  the  wound,  stripping 
off  cortex,  and  running  the  risk  of  rupturing  the  zonule  by  the 
amount  of  pressure  necessary. 

A  somewhat  smaller  and  less  peripheral  incision  has  been 
recommended  in  highly  myopic  eyes,  and  a  proportionately 
larger  section  in  eyes  with  small  corneae.  But  minute  care  in 
proportioning  the  section  is  uncalled  for. 

Intentional  variation  in  tke  size  and  shape  of  the  con- 
junctival  flap  is  mostly  in  the  direction  of  increase  beyond 
the  dimensions  and  design  given  above.  We  have  to 
operate  upon  many  eyes  in  which  the  provision  of  a 
conjunctival  covering  complete  from  end  to  end  of  the 
incision  is  specially  indicated,  to  guard  against  infection. 
When  the  needs  in  this  respect  appear  particularly 
definite,  Czermak's  or  other  sub-conjunctival  operation 
should  be  done.  But  there  are  other  eyes  concerning 
which  one  may  feel  just  a  little  doubtful.  The  conjunctiva 
may  be  secreting  a  little  mucus,  or  there  may  be  a  little 
albumen  in  the  urine,  with  a  trace  of  oedema  about  the 
ankles,  but  not  marked  anaemia ;  or  there  may  be  some 
liability  to  prolapse  of  vitreous,  shown  by  a  tremulous  or 
subluxated  lens  or  '  vitreous  tension,'  or  by  nervousness 
and  unreliability  of  the  patient.  The  need  for  a  protec- 
tive covering  to  the  wound  is  naturally  greater  where  any 
two  of  the  above  indications  are  combined. 

In  making  a  complete  conjunctival  flap,  though  the  site  of 
puncture  through  scleral  and  corneal  tissue  remains  un- 
changed, the  conjunctiva  is  penetrated  a  little  farther  outwards. 
And  in  making  the  counter-puncture,  the  posterior  surface  of 
the  cornea  is  not  entered  till  the  point  of  the  knife  is  about  to 
disappear  behind  the  scleral  rim.  A  very  small  alteration  of 
the  point  of  emergence  of  the  blade  through  the  sclerotic  may 
be  counted  upon  to  result  in  a  considerably  greater  alteration 


So  Cataract  Extraction 

in  the  site  of  perforation   of  the  conjunctiva,  owing  to  the 
tendency  of  the  knife  to  slide  under  the  conjunctiva  here. 

Apart  from  the  haemorrhage  at  the  time  of  operation,  the 
drawback  to  a  large  conjunctival  flap  is  the  separation  of  the 
underlying  wound,*  which  takes  place  afterwards.  At  one 
time  I  attempted  to  prevent  this  by  notching  the  apex  of  the 
flap,  excising  a  small  bit  with  scissors.  In  the  combined 
operation  iris  and  conjunctiva  can  be  excised  together.  But 
the  result  was  not  altogether  satisfactory,  apart  from  the  fact 
that  protection  of  the  wound  is  most  needed  at  its  summit. 
The  notch  frequently  became  filled  up  with  lymph  and  blood- 
clot  sufficiently  to  retain  some  aqueous,  and  so  to  permit  of 
slight  separation  of  the  deep  incision.  And  in  simple  extraction 
there  was  a  slight  tendency  for  iris  to  protrude  at  the  site  of 
the  notch.  The  better  way  to  prevent  any  noticeable  separa- 
tion of  the  sclero-corneal  surfaces  is  to  cut  the  flap  very  short 
— not  more  than  a  millimetre — over  a  considerable  portion  of 
its  extent  (Fig.  50). 


Fig.  50. — A    Complete    Conjunctival    Flap,    shortened   to 
PREVENT  Gaping  of  the  Deep  Wound. 

Involuntary  variations  in  the  section  are  comparatively 
small  and  infrequent,  so  far  as  the  scleral  and  corneal 
tissues  are  concerned,  but  they  occur  almost  constantly  in 
the  outlining  of  the  conjunctival  flap.  One  may  ensure 
that  the  latter  shall  be  complete  or  incomplete,  but  one 
cannot  always  regulate  its  length  and  extent  at  the  sides 
of  the  section  with  any  degree  of  exactitude.  The  elastic 
mucous  membrane,  fixed  only  at  the  corneal  rim,  gives 
to  the  slightest  pressure.  Perhaps  the  most  frequent 
departure   from    the   intended  conjunctival   outline    is   a 

*  This  separation  does  not  take  place  after  Czermak's  or  other  sub- 
conjunctival operation,  in  which  the  mucous  membrane  is  kept 
normally  tense. 


Description  of  the  Operation  8i 

broadening  of  the  flap  at  the  inner  side,  due  to  a  scarcely 
recognisable  deepening  of  the  counter-puncture. 

Small  modifications  in  the  boundary  of  the  conjunctival 
appendage  are,  however,  not  usually  of  much  importance. 
A  defect  or  excess  down  the  sides  of  the  cornea  can  be 
partly  compensated  for  by  broadening  or  narrowing  at  the 
summit  of  the  arch.  Should  the  conjunctival  fringe  be 
quite  absent  down  the  sides  of  the  incision,  owing  to 
straying  of  the  knife  into  purely  corneal  tissue,  it  may 
be  well  to  add  to  the  area  of  the  small  apical  flap,  which 
is  all  that  remains  possible,  by  increasing  its  length  con- 
siderably (Fig.  51), 


Fig.  51. — A  Small  Apical  Conjunctival  Flap,  cut  Long. 

The  making  good  of  any  deficiency  of  the  conjunctival  flap, 
recognized  sufficiently  early,  necessitates  turning  the  edge  of 
the  knife  a  litte  backwards  in  completing  the  sclero-corneal 
section.  To  restrict  the  necessity  for  this  movement  of  the 
knife  as  much  as  possible,  one  may  utilize  the  following  small 
observation  :  During  the  inward  stroke  of  the  knife  the  con- 
junctiva tends  to  be  pushed  into  the  temporal  portion  of  the 
wound,  and  tends  to  be  cut  closer  to  the  cornea  there,  while,  on 
the  other  hand,  the  blade  slides  readily  under  the  conjunctiva 
at  the  nasal  side  of  the  cornea,  and  the  tendency  is  towards 
lengthening  of  the  conjunctival  fringe  there.  Exactly  the 
opposite  tendencies  with  respect  to  the  conjunctiva  are  notice- 
able in  withdrawing  the  knife.  One  may  therefore  enlarge  the 
conjunctival  flap  a  little  by  rocking  the  knife,  as  above 
described,  so  as  to  cut  at  the  nasal  side  only  during  the  inward 
movements,  and  to  cut  at  the  temporal  side  only  during  the 
return  movements. 

Deviations  from  the  correct  line  of  incision  in  the  cornea 
and  sclerotic  are  due  most  often  to  the  incision  being  begun 

6 


82  Cataract  Extraction 

with  the  plane  of  the  blade  at  a  slightly  incorrect  angle.  It 
is  very  difficult  to  judge  always  whether  the  angle  of  the 
knife  is  absolutely  correct  until  the  whole  breadth  of  the 
blade  is  engaged  in  the  puncture.  The  error  more  often 
consists  in  the  edge  of  the  knife  being  turned  a  little  for- 
wards than  backwards.  It  may  pass  unnoticed  until  the 
blade  in  its  course  upwards  becomes  a  little  displaced 
forwards  into  the  cornea. 

Another  occasional  source  of  slight  forward  displacement  of 
the  section  is  the  obliquity  of  the  puncture  in  eyes  with  very 
shallow  anterior  chamber.  One  is  apt  to  forget  that,  since  the 
oblique  plane  of  the  puncture  (Fig.  52,  a)  rapidly  merges  into 
the  transverse  plane  of  the  section  above  (Fig.  52,  b),  this  upper 
portion  comes  to  be  placed  a  little  in  front  of  the  superficial 
(posterior)  end  of  the  puncture  line,  just  as  it  is  a  little  behind 


Fig.  52.— Diagram  to  show  (a)  Oblique  Line  of  Puncture 
IN  AN  Eye  with  Shallow  Anterior  Chamber,  and  its 
Relation  to  (d)  the  Transverse  Plane  of  the  Section 
above. 

the  deep  (anterior)  end  of  the  line.  Therefore,  unless  the 
superficial  insertion  of  the  knife  be  a  little  further  back  in  the 
sclerotic  than  ordinary,  according  to  the  directions  already 
given  for  these  eyes,  the  knife  tends  to  get  in  front  of  the 
limbus  near  the  outer  end  of  the  wound.  Should  this  have 
happened  it  is  well  to  reverse  the  movement  of  the  knife  early, 
as  it  is  easier  to  deepen  the  wound  at  the  outer  side  of  the 
cornea  during  the  outward  movement  of  the  knife.* 

A  shallow  anterior  chamber  may  be  responsible  in  another 
manner  for  a  misplaced  incision.     In  the  somewhat  hurried 

*  Per  contra,  during  the  inward  thrust  there  is  often  perceptible  a 
slight  tendency  to  forward  displacement  of  the  outer  half  of  the 
section.  Possibly  this  sHght  tendency  is  absent  when  fixation  of  the 
globe  is  made  with  the  forceps  applied  at  the  inner  side  of  the  cornea. 


Description  of  the  Operation  83 

cut  needed  to  avoid  wounding  the  iris,  one's  attention  being 
divided  between  the  incision  and  the  iris,  the  former  may  suffer. 

It  is  especially  in  eyes  with  shallow  anterior  chamber  that 
beginners,  by  puncturing  too  obliquely  and  too  far  forwards, 
may  '  split  the  cornea  '  for  a  considerable  distance.  They  may 
fail  to  notice  the  lack  of  that  mobility  and  bright  appearance  of 
the  blade  which  indicate  its  entry  into  the  chamber.  The 
opening  into  the  chamber  may  thus  be  quite  small,  and  the 
wound  need  enlarging  considerably  with  scissors. 

A  cause  of  an  incorrect  section  mentioned  by  up-country 
surgeons  in  India  is  the  use  of  a  '  whippy '  knife — i.e.,  an  old 
worn  instrument,  which  has  become  too  thin  and  too  narrow. 

Straining  of  the  eye  upwards  or  spasm  of  the  orbicularis 
muscle  may  also  interfere  with  the  exact  execution  of  the 
section. 

An  ill  judged  deep  counter-puncture  and  a  knife  held  at  an 
incorrect  angle,  with  its  edge  directed  a  trifle  backwards,  are 
the  causes  of  an  incision  too  deeply  placed,  encroaching  too 
much  into  the  sclerotic.  The  evils  of  a  very  peripheral  section 
(see  Chapter  IV)  were  much  in  evidence  when  von  Graefe's 
'  modified  linear '  extraction  was  in  vogue.  Trouble  from 
haemorrhage  into  the  anterior  chamber  is  accounted  for  both 
by  a  broad  conjunctival  flap,  and  by  section  of  larger  and  more 
numerous  scleral  vessels  than  usual.  Impaction  of  the  iris  and 
capsule  in  the  wound  was  doubtless  the  main  cause  of  the 
destructive  irido-cyclitis  and  sympathetic  ophthalmia,  to  which 
the  Graefe  operation  was  found  especially  liable. 

A  small  variation  in  the  first  thrust  of  the  knife,  either 
voluntary  or  involuntary,  consists  in  sweeping  up  at  the 
nasal  side  more  freely  than  at  the  temporal  side,  using 
the  knife  like  a  scythe.  The  only  trouble  is  a  tendency  to 
protrusion  of  the  iris  at  the  inner  side  below  the  knife,  the  iris 
being  carried  into  the  wound  by  the  flow  of  aqueous  there. 
On  the  other  hand,  it  may  be  useful  to  carry  the  incision 
upwards  at  the  inner  side  as  far  as  possible,  before  an  early 
reversal  of  the  movement  of  the  knife,  necessitated  by  acci- 
dental forward  misplacement  of  the  temporal  part  of  the 
section,  already  considered. 

Other  troubles  associated  with  a  shallow  anterior 
chamber  have  to  do  with  the  iris : 

6—2 


84  Cataract  Extraction 

1.  The  point  of  the  knife,  in  passing  across  a  shallow 
chamber,  is  apt  to  catch  in  the  iris  on  the  near  side  of  the 
pupil.  If  only  a  minute  strand  of  tissue  has  been  taken  up, 
it  may  be  disregarded,  as  it  will  give  way  to  the  onward 
pressure  of  the  blade.  But  if  the  point  be  more  definitely 
engaged  in  the  iris,  to  simply  push  the  blade  onward  would 
often  mean  tearing  a  considerable  portion  of  the  iris  away 
at  its  root,  and  necessarily,  therefore,  a  very  large  and  mis- 
placed iridectomy.  The  instrument  must  be  partially  with- 
drawn to  release  it,  and  the  further  proceedings  must  be 
determined  by  the  amount  of  aqueous  lost  in  the  with- 
drawal. Some  authorities  are  very  much  against  any 
reversal  of  the  movement  of  the  knife  at  this  stage.  But 
in  my  experience  the  needful  withdrawal  usually  entails 
only  a  very  small  escape  of  fluid,  or  possibly  none  at  all. 
And  it  may  be  accepted  that  unless  the  total  loss  of  fluid 
is  sufficient  to  bring  the  iris  bulging  quite  forward  above 
the  edge  of  the  knife,  by  the  time  the  point  of  the  instru- 
ment has  reached  the  site  of  counter-puncture,  the  opera- 
tion may  be  completed  usually  with  only  very  slight  injury 
to  the  iris.  Should,  on  the  other  hand,  the  leakage  of 
aqueous  at  this  stage,  or  before,  be  deemed  too  great,  there 
are  two  alternatives :  adrenalin  may  be  instilled  and 
Czermak's  scissor  operation  performed,  or  the  operation 
must  be  postponed.  In  our  work  any  postponement  must 
be  till  the  irritation  from  the  perchloride  douching  has 
quite  passed  off. 

2.  A  more  common  trouble — the  cutting  of  the  iris  with 
the  knife — mostly  occurs  in  eyes  with  previously  shallow 
chamber.  Indeed,  with  a  very  shallow  chamber  one  is 
perhaps  more  likely  to  cut  the  iris  than  not.  But  the 
small  accident  is  also  moderately  frequent  in  other  eyes, 
owing  to  premature  leakage  of  aqueous  bringing  the  iris 
forward  in  front  of  the  edge  of  the  knife,  unless  the  blade 


Description  of  the  Operation  85 

be  unusually  broad.  The  numerous  incidents  and  con- 
ditions which  lead  to  early  emptying  of  the  anterior 
chamber  have  been  already  mentioned.  The  knife  may 
merely  rub  and  scrape  the  iris,  perhaps  shaving  off  a  thin 
layer  of  it.  Or  the  iris  may  be  *  button  holed,'  the  piece 
removed  extending  through  its  whole  thickness,  but  not 
reaching  the  pupillary  margin.  Or,  in  the  worst  cases,  a 
complete  coloboma  may  be  made.  This  complete  iri- 
dectomy made  by  the  knife*  has  several  disadvantages: 
(i)  It  is  always  unnecessarily  broad.  (2)  I  have  found  it 
frequently  not  symmetrical,  sloping  obliquely  up  and 
out.  This  appears  to  be  due  to  the  fact  that  the  in- 
ward moving  blade  does  not  engage  so  early  and  readily 


Fig.  53. —  Oblique  Iridectomy  made  by  the  Knife. 

in  the  mobile  central  portions  of  iris  as  it  does  towards  the 
periphery,  where  the  membrane  is  firmly  held.  A  strip  of 
peripheral  tissue  (Fig.  53,  a)  is  thus  left  at  the  inner  side 
deprived  of  its  pupillary  zone.  There  is  no  sphincter 
muscle  to  pull  this  strip  of  iris  into  place,  and  this  portion 
is  consequently  very  prone  to  prolapse  subsequently.     I 

*  Bribosia  (Transactions  of  the  International  Congress  held  in 
London,  1873)  and  Katzaurow  {Ci/.  f.  p.  A.,  1884,  S.  370)  purposely 
allowed  aqueous  to  escape  in  order  to  simplify  the  operation  by 
making  the  iridectomy  with  the  knife.  On  the  other  hand,  Bettre- 
mieux  {Arch.  d'Opht,  ix  [1889],  79)  modified  the  Graefe  knife  with 
the  special  object  of  avoiding  any  section  of  the  iris.  He  gave  it  a 
projecting  under  surface  to  raise  the  edge  from  the  iris.  Kuhnt's  and 
Critchett's  knives  were  also  designed  for  this  purpose.  And  Czermak 
used  a  very  broad  Graefe's  knife  (3  to  3*5  millimetres)  to  avoid  cutting 
the  iris.  Melville  Black  (Denver)  prefers  to  withdraw  the  knife  rather 
than  damage  the  iris  with  it.  After  waiting  for  the  aqueous  to 
reaccumulate,  he  introduces  a  special  probe-pointed  knife  to  complete 
the  section. 


86  Cataract  Extraction 

have  several  times  noted  this  particular  form  of  prolapse. 

(3)  This  mode  of  cutting  the  iris,  w^ith  its  accompanying 
rub  and  drag,  is  generally  a  little  painful,  and  is  therefore 
apt  to  provoke  movement  of  the  eye  or  blepharospasm. 

(4)  A  minor  fault  is  that  the  pillars  of  the  coloboma  are 
left  scraped  and  bruised. 

Nearly  all  surgeons,  when  the  iris  comes  forward  above 
the  knife,  proceed  as  if  nothing  had  happened,  and  the 
results  are  as  just  given.  The  bit  of  iris  excised  is 
removed  with  the  iris  forceps  or  washed  out  by  the 
douche. 

Prolapse  of  the  Iris  at  the  time  of  operation,  unasso- 
ciated  with  prolapse  of  vitreous,  occurs  almost  exclusively 
in  our  experience  through  the  nasal  portion  of  the  wound 
during  the  first  long  inward  stroke  of  the  knife.  A 
tendency  to  prolapse,  shown  by  elongation  of  the  pupil, 
may  be  overcome  by  reversal  of  the  movement  of  the 
knife;  but  since  this  reversal  commonly  empties  the 
chamber  of  any  remaining  aqueous,  it  is  not  practised 
unnecessarily  early.  Should  the  iris  have  actually  pro- 
truded, it  is  easily  and  completely  replaced  by  the  back 
of  the  blade  of  the  knife,  the  point  of  the  latter  being  well 
depressed.  The  outward  movement  of  the  knife  is  then 
made  with  the  blade  inclined  thus  upwards  and  outwards, 
as  in  the  rocking  action  already  described.  The  main 
objection  to  allowing  a  prolapse  during  operation  to 
become  large  is  that  the  stretching  and  nipping  of  the 
sphincter  muscle  in  the  wound  must  predispose  slightly 
to  a  recurrence  of  prolapse  after  operation. 

Any  protrusion  near  the  temporal  end  of  the  incision 
might  be  reduced  in  a  similar  way.  Should  the  iris 
protrude  above,  from  too  sudden  completion  of  the  sec- 
tion, with  or  without  pressure  of  the  lids  on  the  eye,  the 
opportunity  might  be  taken  to  perform  the  iridectomy 


Description  of  the  Operation  87 

before  returning  the  iris  (if  the  combined  operation  were 
intended.  This  would  not,  however,  suit  those  operators 
who  prefer  to  seize  the  iris  at  its  pupillary  margin). 

Among  rare  mistakes  and  accidents  may  be  noticed : 

1.  The  rather  humiliating  contretemps  of  finding  that  one 
has  introduced  the  blade  with  its  cutting  edge  downwards.  I 
have  had  no  personal  experience  of  this,  but  have  been  saved 
from  it  on  more  than  one  occasion  by  the  watchfulness  of  my 
assistant.  It  may  be  possible  to  rotate  a  moderately  narrow 
blade  180  degrees  while  still  in  the  puncture,  without  much 
escape  of  aqueous  (according  to  Czermak  and  others).  But 
most  surgeons  would  prefer  to  withdraw  it,  and  to  attempt  its 
reinsertion  through  the  same  opening  (or  parallel  to  it,  Haab). 
The  position  and  procedure  are  the  same  as  are  discussed  on 
p.  84,  the  determining  factor  being  the  amount  of  aqueous  lost. 

2.  Knives  after  resetting  have  on  a  few  occasions  been 
returned  to  us  with  very  attenuated  points.  Once  at  least,  a 
minute  particle  was  broken  off  the  tip  and  left  in  the  tissues 
at  the  counter-puncture,  without  giving  rise  to  any  trouble. 
Terrien  and  others  have  mentioned  similar  breakages. 

3.  Once  a  sudden  outward  movement  of  the  eye  drove  the 
point  of  the  knife  through  the  iris  at  the  inner  side.  A  little 
vitreous  afterwards  apparently  found  its  way  into  the  anterior 
chamber,  though  none  entered  the  section. 

4.  In  one  memorable  case  I  operated  upon  an  eye  with 
conjunctival  fornices  much  retracted  by  scarring.  The  patient 
became  excited  at  the  close  of  the  operation  and  jerked  the 
eye  about.  The  globe  was  so  anchored  to  the  lids  that  the 
movements  pulled  the  wound  open  and  ruptured  the  zonule. 
Loss  of  vitreous  occurred,  and  was  repeated  next  day  at  the 
first  dressing,  and  the  globe  afterwards  shrank.  The  only 
operations  suitable  for  such  eyes  are  the  subconjunctival  ones 
(Czermak's,  Desmarres',  etc.).  It  is  well  to  bear  in  mind  that 
fornices  only  a  little  retracted  may  be  so  fixed  by  the  speculum 
that  extreme  vertical  movements  of  the  globe  may  tend  to  pull 
the  wound  open.  This,  however,  is  more  noticeable  with  an 
ordinary  downward  section  (Chapter  IV)  than  with  the  upper 
one,  because  of  the  comparative  shallowness  of  the  lower  re- 
flection of  conjunctiva.     Where  there  is  a  moderate  degree  of 


88  Cataract  Extraction 

retraction  the  stretching  of  the  ocular  conjunctiva  by  the 
speculum  may  prevent  any  but  a  very  small  conjunctival  flap 
being  made. 

A  final  word  is  necessary  in  closing  this  somew^hat 
appalling  and  bew^ildering  account  of  the  difficulties  which 
beset  the  accomplishment  of  an  apparently  simple  step  of 
the  operation.  The  beginner  cannot  hope  to  bear  in 
mind  all  the  possibilities,  but  fortunately  this  is  not  alto- 
gether necessary.  Though  the  intention  be  often  imper- 
fectly carried  out,  and  though  faults  in  the  section  be  very 
obvious,  the  penalties  incurred  are  seldom  of  any  gravity 
except  in  two  respects.  The  main  essentials  are  (i)  gentle- 
ness throughout,  much  facilitated  by  the  use  of  a  perfect 
knife  ;  and  (2)  watchfulness  against  infection  of  the  wound 
through  soiling  of  the  blade. 

The  temporal  end  of  the  speculum  is  now  at  once  seized 
by  the  assistant,  and  the  instrument  thus  raised,  and  ever 
afterwards  kept  elevated  as  steadily  as  possible.  The 
fixation  forceps  are  handed  over  to  the  assistant,  who 
takes  them  in  his  disengaged  hand.  If,  however,  there  is 
any  decided  tendency  to  spasm  of  the  orbicularis,  it  is 
better  to  remove  the  speculum  now  and  to  trust  to  separa- 
tion of  the  lids  by  the  assistant's  fingers,  or,  better  still,  to 
Desmarres'  elevator  for  the  upper  lid  and  finger  depression 
of  the  lower  lid.  In  this  case  the  assistant  is  not  available 
for  manipulation  of  the  forceps. 

Unless  the  speculum  be  raised  promptly  and  maintained  so, 
its  arms,  pressed  down  upon  the  globe  by  spasm  of  the  lids,  may 
force  the  wound  open  and  be  the  means  of  producing  a  large 
loss  of  vitreous.  Expulsion  of  vitreous  may  take  place  in 
spite  of  elevation  of  the  speculum,  but  much  less  readily.  The 
lids  beyond  the  tarsi  may  still  be  pressed  down  upon  the  eye. 
The  assistant  in  raising  the  instrument  should  take  care  that 
the  outer  canthus  is  pulled  away  from  the  globe,  otherwise  the 


Description  of  the  Operation  89 

pressure  of  the  outer  end  of  the  lids  may  tend  to  expel  the 
ocular  contents.  The  thrust  on  the  speculum  therefore  may- 
have  to  be  a  little  outwards  as  well  as  forwards  if  the  eyeball 
be  prominent. 

To  minimize  the  tendency  to  reflex  spasm  of  the  orbicularis 
the  patient  must  keep  the  other  eye  open,  and  in  many  cases 
his  mouth  also,  and  he  must  breathe  regularly.  Some- 
times it  may  be  necessary  for  an  assistant  to  keep  a  continuous 
watch  upon  the  patient  with  regard  to  these  points.  The 
instillation  of  cocain  in  the  other  eye  has  already  been  men- 
tioned. (We  have  never  practised  it.)  Should  the  patient  show 
signs  of  pain  when  the  iris  is  seized,  it  may  be  wise  to  remove 
the  speculum  and  to  wait  for  a  couple  of  minutes  while  the 
effect  of  further  cocain  instillation  is  obtained.  A  few  reassur- 
ing words  from  the  surgeon  may  be  useful  at  any  time.  But 
some  of  our  poorest  patients  failed  to  respond  to  kindness. 
Accustomed  to  rough  treatment  all  their  lives,  they  could  be 
controlled  only  by  sharp,  angry  tones. 

Timid  people  often  behave  better  during  the  actual  operation 
if  the  Meibomian  expression  and  conjunctival  cleansing  have 
been  done  a  trifle  roughly.  The  comparative  quiet  and  gentle- 
ness afterwards  are  by  contrast  reassuring. 

If  the  hospital  arrangements  are  such  that  patients  awaiting 
their  turn  are  within  sight  and  hearing  of  the  operations  being 
performed,  it  is  most  important  to  begin  with  the  more  docile 
and  intelligent  ones  of  the  batch.  Quiet  behaviour  of  the  earher 
patients  has  a  calming  influence  on  the  remainder,  whereas 
trouble  with  a  stupid  person  at  the  start  alarms  all  the  others. 

One  would  expect,  in  operating  on  the  second  eye  of  a 
patient  a  fortnight  or  so  after  the  first,  to  meet  with  quieter  and 
more  reasonable  behaviour,  but  one  generally  finds  the  patient 
decidedly  less  reliable  and  less  controllable. 

Risk  of  reflex  muscular  contraction  may  be  largely  or  entirely 
eliminated  by  suitable  administration  of  drugs  beforehand.  We 
found  sometimes  that  our  patients  had  been  made  distinctly 
drowsy  by  chloral  and  bromide  (p.  46).  These  overdosed 
patients  could  be  relied  upon  to  keep  their  lids  at  rest  and 
their  eyes  steady,  but  they  could  not  keep  their  eyes  turned 
downwards.  Timid,  excitable  persons  may  need  narcotics  or 
sedatives,  but  stupid,  dull  people  may  be  made  more  stupid 
by  them.     Much  assistance  is  derived  in  this  respect  from  the 


I 

90  Cataract  Extraction 

complete  anaesthesia  obtainable  with  combined  adrenalin  and 
cocain  instillation. 

To  take  charge  of  Desmarres'  or  other  retractor,  the  assistant 
crosses  over  to  the  other  side  of  the  patient.  Before  inserting 
it  behind  the  upper  lid,  now  that  the  incision  has  been  made, 
the  lower  lid  must  be  retracted  well  first  by  the  assistant's 
finger,  and  care  must  be  taken  not  to  let  this  lid  slip  while  the 
elevator  is  in  position.  A  strip  of  gauze  or  lint  is  interposed 
between  the  finger  and  the  skin  of  the  lid  to  prevent  slipping. 
The  assistant  having  only  one  hand  available,  the  retractor  is 
inserted  by  the  surgeon  and  then  handed  over  to  the  assistant, 
who  draws  the  lid  firmly  upward  and  forward,  resting  his  hand 
on  the  patient's  forehead  In  order  to  ensure  that  no  portion 
of  the  lid  muscle  can  still  exert  pressure  on  the  globe,  two 
points  must  be  attended  to  :  (i)  The  outer  canthus  must  be 
removed  from  contact  with  the  globe  by  the  pull  of  the 
retractor  ;  and  (2)  the  eyebrow  must  be  drawn  up  by  the 
ring  and  little  finger  of  the  assistant's  hand  which  holds  the 
retractor.  Smith  of  Jullundur  insists  on  this  point  to  "  unroll, 
as  it  were,  the  orbicularis  muscle,  so  that  a  clear  field  right  up 
to  the  superior  fornix  is  obtained."" 

Czermakf  advised  the  same  drawing  up  of  the  brow  during 
the  use  of  the  stop-speculum.  It  necessitates  the  use  of  the 
assistant's  disengaged  thumb,  and  can  be  accomplished  with- 
out inconveniencing  the  operator  greatly.  But  the  assistant 
is,  of  course,  not  availably  then  for  fixing  the  eye. 

A  retractor  may  be  used  also  for  the  lower  lid,  but  it  takes 
up  a  little  room  in  the  lid  aperture. 

As  with  the  lid  retractor,  so  with  simple  separation  of  the 
lids  by  the  fingers,  a  fairly  experienced  assistant  is  needed.  In 
both  methods  the  palpebral  opening  may  be  scarcely  wide 
enough  if  the  eyes  be  deeply  set  (unless  the  eyes  be  well  turned 
down).  It  is  least  wide  by  simple  finger  separation,  and  by 
this  method  also  the  elevation  of  the  lids  from  the  eyeball  is 
least.  And  only  very  imperfect  control  over  the  orbicularis 
muscle  is  obtained.  It  is  safer  in  this  case  to  release  the  lids 
instantly  when  the  muscle  acts  strongly,  the  eyeball  rolling  up. 

A  firm  hold  must  be  obtained  by  placing  gauze  or  lint  around 

*  The  Ophthalmoscope,  v  (1906),  556. 

■f  'Die  Augenartzlichen  Operationen,'  SS.  908  u.  914. 


Description  of  the  Operation  91 

or  beneath  the  fingers,  and  care  must  be  taken  to  press  only 
upon  the  margins  of  the  orbit,  and  not  upon  the  eyeball.  And 
the  lower  lid  is  the  first  retracted. 


THE    IRIDECTOMY. 

For  this  step  of  the  operation  the  surgeon  takes  up 
iris  forceps  in  his  left  hand  and  scissors,  preferably  de 
Wecker's,  in  his  right  hand.  To  ensure  freedom  from 
risk  of  accident  the  eye  must  be  fairly  steady.  A  sudden 
upward  movement  while  the  ends  of  the  forceps  are  within 
the  globe  might  drive  the  points  against  the  lens  and  dis- 
locate it.  Or.  with  the  forceps  gripping  the  iris  outside 
the  wound,  the  movement  might  tear  a  considerable 
portion  of  the  iris  from  its  base,  perhaps  causing  haemor- 
rhage and  necessitating  a  very  large  iridectomy.  The 
iridectomy  is  more  likely  to  be  a  little  painful  than  any 
other  part  of  the  operation.  The  pain  is  felt  during  the 
drawing  of  the  iris  out  through  the  wound,  and  not  par- 
ticularly during  its  seizure  and  section.  Pain  is  to  be 
anticipated  especially  if  the  patient  winces  slightly  when 
the  fixation  forceps  seize  the  conjunctiva,  or  if  rubbing  of 
the  iris  by  the  knife  during  the  making  of  the  section  has 
provoked  evidences  of  resentment.  In  such  cases  it  is 
safer  to  remove  the  speculum  and  to  instil  more  cocain* 
and  to  wait  for  a  couple  of  minutes,  lest  violent  spasm  of  the 
orbicularis  be  caused  by  the  iridectomy.  In  these  patients, 
and  in  all  who  have  shown  restlessness  or  alarm,  fixation  of 
the  globe  by  the  assistant  is  essential,  though  ordinarily  it 
may  be  dispensed  with.  A  firm  hold  is  taken  upon  the 
conjunctiva  close  to  the  inner  side  of  the  cornea,  and  the 
efficiency  of  the  control  tested  by  a  pull  upon  the  globe. 
Fixation,  now  that  there  is  a  large  wound  in  the  eye,  is 

*  Mayweg  (The  Hague)  prevents  pain  by  instilling  a  drop  of 
I  per  cent,  cocain  solution  into  the  anterior  chamber. 


92  Cataract  Extraction 

necessarily  imperfect.  The  eye  must  be  released  when- 
ever there  is  any  strong  attempt  at  upward  movement, 
lest  the  pull  should  tear  the  zonule.  Still,  by  restricting 
and  delaying  all  movements  the  fixation  forceps  do 
much  to  ensure  the  harmlessness  of  the  movements.  If 
the  operation  be  upon  the  left  eye  the  assistant  must  use 
his  left  hand  for  fixation,  his  other  hand  being  already 
occupied  with  the  speculum.  The  fixing  hand  is  then 
rather  in  the  way  of  the  operator.  The  wrist  has  to  be 
overlaid  by  the  operator's  right  wrist. 

To  ensure  the  easy  performance  of  the  iridectomy  the 
eye  must  be  turned  downwards,  unless  it  be  unusually  pro- 
minent. The  operator's  left  hand,  holding  the  iris  forceps, 
rests  on  the  patient's  forehead.  The  right  hand,  holding 
the  scissors,  is  placed  in  position  across  the  patient's  face, 
so  that  the  two  bades  of  the  scissors  are  pointing  upwards 
near  the  wound.  The  points  of  the  forceps  are  introduced 
closed  at  the  summit  of  the  wound,  pointing  directly 
downwards.  During  the  insertion  they  are  kept  free  from 
entanglement  in  the  loose  conjunctival  flap  by  slight  lateral 
movements,  and  by  backward  pressure  upon  the  sclerotic. 
Or  the  conjunctival  flap  may  be  drawn  forward  by  the 
point  of  one  of  the  scissor  blades,  after  which  the  scissors 
are  again  placed  in  the  position  above  mentioned.  Should 
the  conjunctival  flap  have  been  turned  down  over  the 
cornea  on  account  of  haemorrhage,  it  is  left  so,  though  if 
long  it  may  prevent  the  operator  seeing  the  points  of  the 
forceps  in  the  anterior  chamber. 

Having  arrived  at  a  point  midway  between  the  base  and 
pupillary  margin  of  the  iris,  the  forceps  resting  upon  the 
iris  are  simply  opened  to  a  distance  of  2  millimetres  or 
less,  and  closed  again,  in  the  expectation  that  the  iris  will 
be  thus  seized.  The  instrument  is  slowly  withdrawn 
through  the  wound,  bringing  a  small  loop  of  iris  with  it. 


Description  of  the  Operation 


93 


While  this  is  being  done  the  scissor  blades,  somewhat 
approximated  (Fig.  54),  are  pressed  down  upon  the 
incision,  one  on  either  side  of  the  loop  of  iris.  This  tends 
to  limit  the  size  of  the  loop  drawn  out,  and  the  scissors 
are  ready  in  position  to  snip  at  once  in  case  the  eye  should 


Fig.  54. — The  Iridectomy. 

begin  to  move  upwards.  And  the  conjunctival  flap  may 
be  also  thus  pressed  downwards,  baring  the  iris.  But  if 
the  flap  is  too  large  it  may  be  left  covering  the  iris,  and 
some  of  it  cut  away  with  the  iris.  The  pull  upon  the  iris 
is  continued  until  its  pupillary  margin  lies  between  the 
scissor  blades.  The  latter  are  then  closed,  and  the  iridec- 
tomy is  completed. 


94 


Cataract  Extraction 


There  are  many  patients,  however,  who  are  unable  to 
maintain  the  desired  downward  rotation  of  the  globe.  And 
it  is  a  great  mistake  to  worry  the  patient  with  repeated 
urgings  to  look  down.     For  when  control  has  been  lost 


Fig.  55. — The  Cornea  is  forced  down  by  the  Iris  Scissors, 

TUCKED     into     THE    CONJUNCTIVAL     FLAP,    TO    EXPOSE    THE 

Iris  for  Seizure  by  the  Forceps. 


to  a  great  extent,  the  greater  the  movement  of  the  eye 
from  the  position  of  rest,  the  earlier  and  more  certain  will 
be  the  recoil  movement,  passing  beyond  the  position  of 
rest.  Even  in  the  case  of  a  deeply  set  eye,  if  it  only 
be  kept  comparatively  motionless,  the  iridectomy  can  be 


Description  of  the  Operation  95 

done  without  any  downward  rotation,  thus.  The  wound 
now  lying  behind  the  upper  lid  (which  is  pressed  well 
forward  by  the  supported  speculum),  the  iris  forceps  can 
no  longer  be  passed  down  through  the  incision.  It  is 
necessary  that  the  wound  shall  be  opened  by  displacing 
the  corneal  flap  downwards,  to  expose  the  iris  sufficiently 
for  the  forceps  to  be  used  with  points  directed  laterally  or 
backwards.  It  is  to  be  reckoned  as  one  of  the  definite 
advantages  of  a  conjunctival  flap  that  it  furnishes  a  ready 
and  safe  means  of  thus  opening  the  wound.  The  closed 
scissor  points  (de  Wecker's),  directed  backwards  or  side- 
ways, are  utilized  to  push  down  the  conjunctival  flap. 
They  readily  obtain  a  hold  upon  the  loose  tissue,  and 
thus  enable  the  edge  of  the  cornea  to  be  forced  down- 
wards for  a  moment  (see  Fig.  55).  The  forceps  points 
in  gripping  the  iris  need  not  enter  the  globe  at  all.  The 
cutting  of  the  iris  must  not  be  done  with  the  scissors 
held  transversely,  as  this  would  produce  a  wide  coloboma 
instead  of  the  very  narrow  one  desired.  Therefore  no 
pull  is  made  upon  the  seized  iris  until  the  scissors  are 
in  the  correct  position  for  cutting,  lest  slight  pain  excited 
by  the  pull  should  cause  the  eye  to  rise  upwards.  The 
iris  must  be  quickly  released  when  any  movement  of  the 
globe  appears  too  powerful  to  be  controlled  by  the  fixing 
forceps,  lest  a  large  irido-dialysis  be  produced. 

There  are  three  details  which  always  deserve  attention. 
Firstly,  the  iris  should  not  be  drawn  out  of  the  wound 
farther  than  is  necessary,  in  order  that  the  sphincter 
muscle  may  not  be  unduly  stretched.  (The  stretching 
of  the  pupillary  zone  of  iris  is  further  reduced  to  a  mini- 
mum by  seizing  the  iris  as  above  directed,  at  some 
distance  from  the  pupillary  margin.) 

Secondly,  no  more  iris  is  cut  away  than  is  essential  to 
obtain  a  coloboma  extending  from  the  base  of  the  iris  to 


9^  Cataract  Extraction 

the  pupil.  Thus  as  little  of  the  sphincter  is  removed  as 
practicable.  Active  sphincter  muscle  fibres  are  one  of  the 
chief  preventives  of  subsequent  prolapse  or  incarceration 
of  the  iris  in  the  wound.  They  should  suffice  now  to 
draw  the  iris  back  into  position  within  the  globe. 

Thirdly,  great  weight  has  been  laid  by  Knapp*  and 
others  (Horner,  Snellen,  Gayet,  Alf.  Graefe,  Czermak) 
upon  the  necessity  for  immediate  and  complete  replace- 
ment of  the  iris. 

With  the  iridectomy  performed  as  just  described,  spontaneous 
retraction  of  the  iris  is  nearly  always  complete.  In  Bombay, 
therefore,  no  particular  attention  was  found  necessary  in  this 
matter.  The  means  of  replacement  are  given  under  '  Toilet  of 
the  Eye.'  The  readjustment  must  be  repeated,  if  necessary,  after 
the  delivery  of  the  lens  and  after  the  removal  of  cortical  remains. 
But  it  is  held  that,  provided  the  reposition  is  properly  done  after 
the  iridectomy,  it  seldom  needs  repetition  later.  Inclusion  of 
either  pillar  of  the  coloboma  in  the  wound  is  shown  by  upward 
displacement  of  its  projecting  pupillary  angle.  Impaction  of 
both  pillars  produces  vertical  elongation  of  the  pupil.  If  they 
be  allowed  to  remain  in  the  wound  during  the  expulsion  of  the 
lens,  complete  reposition  afterwards  may  be  impossible.  For 
the  sphincter  is  likely  to  become  weakened  temporarily  by 
stretching  of  the  iris,  folded  in  front  of  the  lens,  and  by 
the  squeezing  to  which  it  is  subjected  between  the  lens  and 
the  cornea.  The  iris  afterwards,  nipped  in  the  angles  of  the 
wound,  may  be  further  held  by  congestive  swelling  of  the 
impacted  tissue  (?),  or  by  transparent  capsule  lying  in  the 
incision. 

Proper  care  in  this  respect  is  nearly  always  an  effective 
safeguard  against  the  complication  which  has  been  counted  the 
chief  reproach  of  combined  extraction — subsequent  incarcera- 
tion of  the  iris  in  the  angles  of  the  wound,  with  its  consequences, 
cystoid  cicatrix,  liability  to  late  infection,  etc. 

Close  approximation  of  the  pillars  of  the  coloboma,  as  a  pre- 
liminary to  expulsion  of  the  lens,  appears  to  be  unnecessary, 
and  even  undesirable.     It  has  been  our  usual  practice  to  push 

*  A.f.  A.,  xi,  (1882)  49. 


Description  of  the  Operation  97 

the  margins  of  the  coloboma  apart  with  the  cystitome  after 
making  the  capsulotomy,  to  make  way  for  the  lens,  merely 
anticipating  the  widening  which  would  otherwise  be  accom- 
plished by  the  lens  itself.  The  important  point  is  that  the 
iris  should  lie  quite  flat  and  even,  without  any  tendency  to 
entanglement  in  the  wound. 

Smith  of  Jullundur  causes  the  iris  to  prolapse,  and  so  avoids 
introducing  the  iris  forceps  within  the  wound.  "  He  dimples 
in  the  cornea  close  to  its  free  edge  with  one  limb  of  the  iris 
forceps,  thus  causing  the  edge  of  the  iris  to  appear  outside  the 
wound  ;  at  the  same  time  the  other  limb,  which  is  resting  on 
the  sclerotic  above,  is  slid  along  so  that  the  iris  is  lightly 
caught  in  its  grasp,  pulled  outside,  and  cut  off  in  the  usual 
manner,"*  (Axenfeld  has  caused  the  iris  to  prolapse  similarly 
for  the  performance  of  iridotomy.) 

During  a  cataract  operation  the  contractility  of  the  pupil  is 
not  usually  demonstrable  after  the  section  has  been  made.  But 
sometimes  I  have  noticed  considerable  activity  of  the  sphincter 
muscle  after  making  such  an  iridectomy  as  above  described,  in 
operating  for  adherent  leucoma.  With  the  smaller  wound, 
and  the  anterior  chamber  perhaps  not  completely  empty,  the 
lightest  touch  upon  the  iris  with  spatula  may  produce  marked 
contraction  of  the  pupil  and  coloboma,  repeated  as  often  as 
desired,  drawing  the  iris  away  from  the  wound. 

In  attempting  to  remove  as  little  of  the  sphincter  as  possible, 
one  is  very  apt  to  buttonhole  the  iris,  leaving  a  band  of  tissue 
separating  the  coloboma  from  the  pupil.  This  is  more  likely 
to  happen  if  the  iris  prolapses  on  completion  of  the  section. 
The  iris  is  then  often  seized  too  near  its  base.  A  bridge  of 
tissue  is  also  often  left  when  the  iridectomy  is  unintentionally 
made  with  the  knife  during  the  cutting  of  the  section.  The 
band  is  commonly  too  narrow  to  be  gripped  by  iris  forceps 
passed  down  in  the  ordinary  way.  It  might  be  withdrawn  by 
a  Tyrrell's  hook,  rapidly  sterilized  in  the  flame;  but  the 
necessary  rotation  of  the  hook  in  catching  and  withdrawing 
the  band  is  rather  awkward  with  the  left  hand,  and  the  instru- 
ments at  hand  suffice. 

The  narrow  strip  of  tissue  may  be  readily  hooked  upwards 
by  the  cystitome  (held  in  the  right  hand)  after  the  capsulotomy 

*  Rutter  Williamson,  The  Ophthalmoscope^  v  (1907),  558. 

7 


98  Cataract  Extraction 

has  been  done.  If  very  narrow,  it  tears  readily.  Otherwise 
the  loop  is  released,  and  the  forceps  and  scissors  again  taken 
up.  The  forceps  are  used  so  that  one  blade  passes  down  in 
front,  and  the  other,  generally  more  or  less  embedded  in  soft 
lens  matter,  behind  the  band.  This  will  still  be  found  lying 
near  the  wound,  retraction  being  interfered  with  by  the  sticky 
lens  substance.  The  points  of  the  forceps  being  closed  beyond 
the  band,  the  latter  may  then  be  readily  hooked  up  and  cut 
away.  Or  if  the  eye  be  very  unsteady  the  forceps  may  be  dis- 
pensed with.  The  left  hand  may  be  usefully  employed  with 
the  curette  or  expressing  hook.  Pressure  is  applied  at  the 
lower  edge  of  the  cornea,  as  for  expulsion  of  the  lens.  The 
wound  is  thus  forced  open,  and  the  little  band  of  iris  stretched 
and  carried  forward  on  the  presenting  lens,  either  into  the 
wound  or  near  it,  so  that  it  may  be  easily  cut  with  scissors. 
Usually  the  strip  of  iris  may  be  made  to  present  sufficiently 
well  for  the  scissor  blades  to  be  applied  transversely,  snip- 
ping off  lens  substance  together  with  the  iris.  Should  by 
chance  a  long  tag  be  left  attached  to  one  angle  of  the 
coloboma,  this  shrinks  afterwards,  but  forms  a  posterior 
synechia. 

In  cases  where  the  iris  has  already  prolapsed  through  the 
incision,  it  has  been  recommended  to  reduce  the  prolapse  in 
order  to  seize  the  iris  at  the  point  desired  for  making  the 
iridectomy.  But  this  is  an  unnecessary  prolongation  of  the 
operation,  and  is,  perhaps,  theoretically  inadvisable  on  account 
of  infective  risks  where  the  protruded  iris  has  come  into 
contact  with  the  conjunctiva. 

The  presence  of  a  number  of  posterior  synechiae  does  not 
alter  the  procedure  to  any  extent.  In  order  to  tear  away  an 
adhesion,  the  iris  is  seized  as  close  to  it  as  possible. 

If  the  eye  be  unsteady,  it  may  be  convenient  and  permissible 
to  perform  the  iridectomy  a  little  to  one  side  instead  of  straight 
upwards. 

It  is  surprising  that  the  section  of  the  healthy  iris  should 
give  rise  to  no  haemorrhage.  Bleeding  is  almost  confined  to 
cases  in  which  the  iris  shows  evidences  of  past  inflammation. 
In  glaucomatous  eyes  it  might  occur  were  the  iridectomy  not 
usually  performed  beforehand.  Haemophilia  and  atheroma  of 
so  high  grade  as  to  lead  to  bleeding  from  the  blood-vessels  of 
the  iris  are  both  too  rare  to  need  special  consideration. 


Description  of  the  Operation  99 

The  object  of  the  iridectomy  is  twofold.  A  minor 
service  rendered  is  in  facihtating  the  deKvery  of  the  lens 
by  furnishing  a  direct  passage  upwards.  Secondly,  much 
more  important,  it  renders  prolapse  of  iris  after  operation 
much  less  frequent  than  it  would  otherwise  be.  It  does 
this  by  allowing  the  lens  to  escape  without  stretching,  and 
thereby  weakening  the  pupillary  sphincter,  and  still  more, 
perhaps,  by  providing  an  open  gateway  for  the  later  direct 


Fig.  56. — 'Key-hole'  Combination  of  Coloboma  and  Pupil. 

escape  of  fluid  from  the  posterior  chamber — fluid  which 
might  otherwise  carry  the  iris  into  the  wound  whenever 
the  early  adhesion  of  the  latter  were  temporarily  broken 
down. 

The  '  key-hole '  combination   of  pupil   and   coloboma 


® 


Fig.  57.— Coloboma  Pointed  Fig.  58. — Sphincterec- 

Upwards.  tomy. 

appears  to  obtain  these  objects  in  the  fullest  manner, 
while  sacrificing  but  little  of  the  valuable  sphincter 
muscle. 

Many  operators — e.g.  Galezowski  * — perform  only  a  partial 
iridectomy  or  '  sphincter ectomy,'  taking  away  only  a  small 
piece  of  the  pupillary  zone  of  iris.  Or  a  slightly  larger  iridec- 
tomy is  made,  removing  a  piece  of  tissue  widest  at  the  pupil 
and  tapering  upwards  to  a  point.  The  tissue  excised  is  pre- 
cisely that  which  can  be  least  well  spared,  and  the  opening  for 
gushes  of  fluid  from  the  posterior  chamber  is  absent,  or  least 

*  Rec.  aOpht.,  1892,  p.  262. 

7—2 


lOO 


Cataract  Extraction 


< 

O 


o 


pq 
I— ( 

h4 


wide,  where  it  is  most  needed.  If  not  effective  against  prolapse 
and  incarceration,  the  iridectomy  might  as  well  be  omitted, 
except  in  cases  of  rigid  pupil. 

Chibret*  and  Dianoux  (Nantes)  reduced  the  excision  of  iris  to 
the  minimum  by  cutting  with  fine  scissor  blades  introduced 
into  the  anterior  chamber.     No  iris  forceps  were  used. 

Formerly,  it  was  a  common  practice  for  the  surgeon  to  share 
his  responsibility  with  the  assistant,  the  latter  actually  dividing 
the  iris,  the  surgeon  merely  fixing  the  globe  and  drawing  the 
iris  out  of  the  wound. 

In  von  Graefe's  peripheral  linear  operations  under  general 
anaesthesia  the  iris  nearly  always  became  prolapsed.  A  broad 
piece  was  removed  by  two  snips  of  the  scissors.  Von  Arlt,  in 
order  to  avoid  incarceration,  made  a  very  broad  coloboma, 
dividing  the  iris  with  curved  scissors  along  its  base,  and 
radially  at  the  two  ends  of  the  incision.  De  Weckert  com- 
monly made  a  narrow  coloboma  with  his  iris  scissors  (pince- 
ciseaux).  It  was  pointed  or  with  parallel  sides,  and  extended 
to  the  base  of  the  iris.  This  narrow  iridectomy,  recommended 
also  by  Swanzy  and  Fuchs  as  an  effective  preventive  of  prolapse, 
came  to  be  adopted  generally.  In  the  making  of  a  very  narrow 
coloboma  many  surgeons  have  used  an  iris  hook  instead  of 
forceps  for  withdrawing  the  iris. 


THE  OPENING  OF  THE  CAPSULE. 

The   opening   in   the   anterior   capsule  is  designed   to 

serve  for  the  easy  exit  of  the  lens  in  one  mass,  and  to 

provide  a  central  clear  space  for  direct  vision.     At  the 

same  time,  it  is  well  to  avoid,  if  possible,  leaving  a  loose 

flap  of  capsule  above,  liable  to  impaction  in  the  wound. 

These  ends  may  be  attained  by  (i)  simple  division  with 

some  form  of  cystitome,  curved  needle,  or  sharp  hook ;  or 

(2)  tearing  away  a  portion  of  the  membrane  with  capsule 

forceps ;  or  occasionally  (3)  the  successive  use  of  cystitome 

and  forceps. 

*  T^ec.  d'Opht.,  1884,  p.  77. 

t  '  Chirurgie  Oculaire,'  p.  57  (Paris,  1879). 


Description  of  the  Operation  loi 

Capsulotomy  with  cystitome  or  sharp  lens  hook.  In 
the  large  majority  of  combined  extractions  I  have  been 
content  with  a  single  vertical  or  oblique  incision  or  tear 
with  Graefe's  bent  cystitome — an  incision  considered  out 
of  date  by  many  authorities.  It  has  been  held  that  this 
toothed  instrument,  like  the  sharp  lens  hook,  commonly 
tears  the  capsule  instead  of  cutting  it,  and  that  all  tears 
directed  towards  the  wound  are  contra-indicated,  in  that 
the  effect  of  any  such  pull  of  the  tooth  upon  the  capsule 
is  to  produce  a  pointed  loose  tongue  of  membrane,  with 
base  upwards,  likely  to  be  carried  into  the  wound  by  the 
escaping  lens.  But  for  some  years  past  I  have  been  in 
the  habit  of  examining  the  capsules  of  nearly  all  our 
patients  before  their  discharge,  and  have  not  seen  reason 
to  alter  our  general  plan  of  work. 

Procedure.  —  The  eyeball  is  again  turned  downwards, 
and  the  fixation  forceps  are  necessary  if  the  eye  be 
unsteady.  But  in  a  quiet  patient  it  is  better  to  dispense 
with  fixation,  because  it  is  now  necessarily  imperfect,  and 
because  it  is  more  likely  to  be  felt  by  the  patient,  and 
therefore  more  likely  to  excite  attempts  at  movement, 
than  the  capsulotomy  itself.  I  prefer  to  use  always 
von  Graefe's  bent  cystitome,  employing  for  both  eyes  the 
one  intended  for  use  upon  the  right  eye  (Fig.  24  a).  It 
is  placed  for  introduction  into  the  wound  with  its  bent 
end  portion  directed  transversely.  Whichever  eye  be 
operated  upon,  the  instrument  is  held  in  the  right  hand, 
its  end  pointing  to  fhe  left  and  the  sharp  tooth  directed 
upwards  (see  Fig.  59).  The  hand  is  supported  on  the 
patient's  forehead.  The  sloping  stem  of  the  instrument, 
between  the  bend  and  the  handle,  is  steadied  against  the 
tip  of  the  left  forefinger  or  middle  finger.  This  horizontal 
presentation  of  the  terminal  portion  of  the  stem — that  which 
has  to  enter  the  globe — removes  all  risk  of  its  touching  the 


I02 


Cataract  Extraction 


upper  lid  margin  or  lashes,  supposing  the  ordinary  bar 
speculum  be  in  use.  But  this  direction  is  adopted  and 
maintained  as  long  as  possible,  mainly  to  guard  against 
the  risk  of  injury  by  the  instrument  in  case  the  eye  should 
unexpectedly  roll  upwards. 


Fig.  59.— Insertion  of  the  Cystitome. 
(The  conjunctival  flap  happens  to  be  turned  down  in  this  case.) 

The  end  of  the  cystitome  is  easily  inserted  under  the 
conjunctival  flap,  passed  down  in  the  chiamber,  and  then 
usually  changed  in  direction,  swinging  around  the  tip  of 
the  left  index  finger  as  a  fixed  point.  In  a  perfectly  quiet 
eye  a  long  vertical  cut  may  be  made  in  the  capsule,  pass- 


Description  of  the  Operation  103 

ing  exactly  through  the  centre  of  the  pupil.  For  this  the 
end  of  the  cystitome  is  passed  down  beyond  the  lower 
pupillary  margin,  behind  the  iris.  It  is  then  rotated  on 
its  axis  to  direct  the  tooth  backwards  on  to  the  capsule, 
and  then  somewhat  sharply  withdrawn  upwards,  to  make 
the  required  capsular  puncture  and  its  extension  upwards. 
Usually  this  single  movement  is  effective  if  the  capsule 
be  not  much  thickened  and  the  tooth  of  the  instrument  be 
moderately  sharp  and  free  from  blood-clot.  In  lenses 
with  soft  cortex  the  puncture  of  the  capsule  is  signalized 
by  a  forward  movement  of  some  of  the  contents,  and  in 
Morgagnian  cataracts  the  escape  of  fluid  is  at  once  seen. 
In  those  with  firm  cortex  the  impression  of  the  point  of 
the  instrument  in  the  cortex  may  usually  be  seen,  unless  it 
it  is  obscured  by  blood  in  the  anterior  chamber.  If  there 
is  any  doubt  about  the  opening  of  the  capsule,  an  up-and- 
down  "  scratching  "  movement  of  the  cystitome  is  added. 
A  horizontal  movement  of  the  instrument  to  either  side 
near  the  wound  serves  to  ensure  a  wide  opening  of  the 
slit  in  the  capsule,  and  to  separate  the  pillars  of  the 
coloboma  of  the  iris.  The  cystitome  is  then  again  rotated, 
so  that  the  tooth  points  sideways.  It  can  then  be  with- 
drawn from  the  wound.  It  is  most  important  throughout 
to  avoid  pressure  upon  the  lens,  likely  to  displace  it  back- 
wards, rupturing  the  zonule. 

The  ordinary  short  tooth,  i  millimetre  or  less  in  length, 
is  used  pointing  directly  backwards.  Some  cystitomes 
are  made  with  distinctly  longer  teeth.  A  rather  long 
tooth  must  point  only  obliquely  backwards*  lest  it 
become  embedded  in  firm  lens  substance,  displacing  the 
lens  upwards  and  tearing  its  suspensory  ligament,  or  lest 

*  A  minor  disadvantage  of  the  long  tooth  directed  very  obliquely 
is  that  one  cannot  see  exactly  what  portion  of  the  slanting  edge  of  the 
tooth  is  cutting  the  transparent  capsule,  and  so  one  has  not  perfect 
command  over  the  location  of  the  incision. 


I04  Cataract  Extraction 

the  direct  pressure  of  the  tooth,  working  in  an  empty 
anterior  chamber,  depress  the  lens  and  thus  rupture  the 
ligament.  A  slight  upward  displacement  of  a  lens  with 
a  firm  cortex  is  not  uncommon  even  with  a  short-toothed 
instrument.  It  is  merely  sufficient,  however,  to  place  the 
upper  margin  of  the  lens  behind  the  scleral  lip  of  the 
wound.  And  if  recognized,  or  even  suspected,  it  can  be 
at  once  rectified  by  a  small  downward  stroke  of  the 
cystitome. 

In  operating  on  a  Morgagnian  cataract  the  oblique 
direction  of  a  long  *  tooth  '  is  essential  also  to  avoid  the 
risk  of  puncturing  the  posterior  capsule  on  the  collapse  of 
the  sac. 

Blood-clot  in  the  anterior  chamber  is  a  minor  trouble. 
It  prevents  one  seeing  what  is  being  done,  and  unless  the 
cystitome  happen  to  be  insinuated  quite  behind  the 
coagulum,  the  tooth  becomes  entangled  in  it  and  thus 
prevented  from  cutting.  Yet  one  may  prefer  to  proceed 
at  once  with  the  capsulotomy  rather  than  make  any 
prolonged  attempt  to  wash  away  the  clot  with  the  douche. 
One  must  use  the  cystitome  with  to-and-fro  scratching 
action  to  penetrate  the  hidden  capsule.  Perforation  of 
the  membrane  will  be  shown  by  the  appearance  of  cortex 
in  the  clot  beside  the  cystitome,  if  the  cortex  be  soft. 
But  in  lenses  with  firm  cortex  there  is  no  immediate 
evidence  of  perforation  obtainable  in  these  cases.  A  sharp 
cystitome  is  advisable.  And  since  one  must  work  by  the 
sense  of  touch  alone,  little  more  than  the  weight  of  the 
instrument  should  be  allowed  to  press  on  the  lens.  After 
three  or  four  up-and-down  movements,  one  may  assume 
with  a  fair  degree  of  certainty  that  a  sufficient  opening 
has  been  made.  One  proceeds  to  express  the  lens,  and 
one  relies  upon  refusal  of  the  lens  to  pass  upwards  as 
evidence  that  the  attempt  at  capsulotomy  has  failed. 


Description  of  the  Operation  105 

Another  difficulty  lies  in  restlessness  of  the  eyes.  Since 
uncontrolled  movements  of  the  globe  are  nearly  always 
primarily  upwards,  there  may  be  considerable  danger  in 
introducing  an  instrument  far  within  the  globe,  directed 
vertically  or  nearly  so.  Therefore,  unless  steadiness  of 
the  eye  can  be  confidently  expected,  the  cystitome  must 
only  point  obliquely,  and  if  the  eye  be  very  unsteady  the 
direction  of  the  instrument  can  depart  but  little  from 
the  horizontal.  And  these  inclinations  are  the  only  ones 
available  in  patients  who  cannot  at  this  stage  any  longer 
look  downwards.  The  tooth,  with  flat  sides  and  single 
cutting  edge,  can  only  be  expected  to  cut  by  withdrawal 
movements  in  the  line  of  the  stem.  A  long  oblique,  or 
even  transverse,  division  of  the  capsule  furnishes  an 
opening  perfectly  satisfactory  for  vision,  provided  that  it 
passes  through  a  point  a  little  helow  the  centre  of  the  pupil. 
Indeed,  the  direction  of  the  cut  appears  to  be  immaterial 
provided  its  position  is  correct.  In  a  large  proportion  of 
cases  the  elastic  retraction  of  the  membrane  cannot  be 
depended  upon  to  effectually  widen  the  slit.  If  an  oblique 
cut  be  made  across  the  pupil,  the  lower  leaflet  of  the 
anterior  capsule  will  frequently  remain  in  position,  only 
the  upper  leaflet  being  permanently  displaced  upwards 
and  to  the  side  behind  the  iris.  Unless  the  line  of  division 
pass  below  the  centre  of  the  pupil,  the  edge  of  the  lower 
portion,  therefore,  lies  across  or  near  the  line  of  vision, 
uniting  with  the  posterior  capsule,  and  disturbing  sight  by 
opacity  developing  in  its  epithelial  lining.  This  single- 
leaf  displacement  may  be  anticipated  frequently  even 
where  the  deviation  of  the  line  of  incision  from  the  vertical 
is  quite  moderate. 

Though  the  instrument  lie  in  the  chamber  obliquely,  it 
may,  if  preferred,  be  withdrawn  vertically  in  an  attempt 
to  tear  the  capsule  vertically  with  the  side  of  the  tooth, 


io6  Cataract  Extraction 

especially  if  the  capsule  be  thin  and  transparent.  But 
such  tearing  is  apt  to  be  productive  of  loose  points  of 
capsule  liable  to  impaction  in  the  wound. 

It  is  necessary  now  to  consider  how  the  single  long 
incision  or  tear,  preferably  vertical  or  nearly  so,  fulfils 
the  requirements  laid  down. 

Knapp*  believes  that  "the  vertical  splitting  is  unfavourable 
for  the  exit  of  the  lens ;  the  horizontal,  parallel  to  the  corneal 
section,  offers  its  easiest  escape.  .  .  .  The  next  and  worst 
drawback  of  the  vertical  splitting  is  that  it  produces  a  more  or 
less  dense  scar,  which  is  much  in  the  way  of  the  light,  and 
which  is  very  unpleasant  to  divide  by  a  later  capsulotomy. 
Graefe  made  not  only  a  vertical  split  in  the  capsule,  but  also  a 
horizontal  one  at  the  periphery  of  the  coloboma.  He  opened 
the  capsule  horizontally  in  the  upper  part  with  a  cystitome, 
which  he  then  turned,  and  with  it  ripped  the  capsule  from 
below  upward  to  meet  the  horizontal  incision.  In  this  way  he 
obtained  a  broad  T-shaped  opening,  which  did  not  always 
remain  large  enough,  and  my  imitation  of  his  procedure  in 
Heidelberg  and  in  New  York  proved  no  more  obliging." 

The  single  slit  is  evidently  the  simplest  procedure  applicable ; 
it  necessitates  the  retention  of  the  instrument  within  the 
anterior  chamber  for  only  a  very  short  period  of  time.  Thus, 
we  never  had  to  chronicle  accidental  dislocation  of  the  lens 
from  movement  of  the  globe,  driving  the  lens  forcibly  against 
the  instrument.  The  deliberate  manipulation  by  some  opera- 
tors with  the  cystitome  or  hook  directed  downwards  far  within 
the  chamber,  appear  to  indicate  that  the  average  European 
patient  is  much  quieter  and  more  reliable  than  in  Bombay. 
In  most  of  our  work  the  risk  of  accident  from  prolonged 
insertion  of  the  cystitome  certainly  appeared  to  outweigh  any 
possible  benefit  from  an  elaborately  planned  capsulotomy. 
We  had  to  be  constantly  wary  to  withdraw  the  instrument 
quickly  on  any  movement  of  the  globe. 

And  it  is  well  recognized  that  in  working  upon  a  practically 
invisible  and  more  or  less  elastic  membrane,  additional  move- 
ments of  a  toothed  cystitome  after  the  first  opening  has  been 
made   may   serve   merely   to   widen    the  opening   instead   of 

*  Amer.  Journ.  of  Ophth.,  September,  1905. 


Description  of  the  Operation  107 

incising  the  capsule  afresh.  The  sharp  point  must  be  carried 
well  away  from  the  primary  incision  to  puncture  afresh  for  any 
additional  division. 

We  frequently  used  a  cystitome  with  tooth  blunted  from 
numerous  passages  through  the  flame  of  a  spirit-lamp.    Yet  sub- 


FiG.  60. — Y-Shaped  Capsular  Opening.    (About  two  weeks  after 

operation.) 

sequent  evidences  of  incision,  as  distinct  from  tearing,  were  quite 
numerous  in  the  forms  shown  in  Figs.  63,  65,  66,  and  67.  Until 
we  realized  how  frequently  the  displacement  of  the  capsule  is 
due,  largely  or  entirely,  to  the  passage  of  the  lens,  we  several 


Fig.  61.— V-Shaped  Opening,  with  Tongue  of  Capsule 
Above.     (Seen  on  discharge  from  hospital.) 

times  had  to  *  needle '  after  an  oblique  incision,  passing  across 
the  centre  of  the  pupil,  simply  because  of  insufficient  displace- 
ment of  the  lower  leaf,  as  shown  in  Fig.  64.  Doubtless  the 
blunt  point  frequently  tore  the  membrane,  however,  and  this 


Fig.  62. — V-Shaped  Opening.  Margins  show  a  Deposit  of 
Fibrin.  Anterior  Capsule  shows  slight  Punctate 
Opacity.     (Eight  days  after  operation.) 

'probably  accounted  for  many  triangular  openings,  as  in 
Figs.  60,  61,  and  62,  with  apex  downwards  and  base  generally 
not  visible.  That  this  form  of  opening  had  resulted  from  a 
V-shaped  tear  of  the  capsule  is  evident  in  Figs.  60  and  61, 
from  the  displaced  tongue  of  membrane  seen  above.  But 
usually  no  such  projecting  piece  of  membrane  could  be  seen 


io8  Cataract  Extraction 

above,  and  the  opening  (Fig.  62)  might  well  result  from  a 
vertical  or  oblique  incision,  plus  a  horizontal  tear  above.  Both 
the  tear  and  the  widening  of  the  vertical  slit  above  may  result, 
either  from  the  lateral  movement  of  the  cystitome  or  from  the 


Fig.  63. — Oblique  Incision  in  Capsule,  Partly  Bordered  bv 
Pigment.     (Eleven  days  after  operation.) 
n.  Cortex. 

passage  of  the  lens,  and  the  permanent  widening  of  the  slit 
may  be  maintained  by  the  posterior  synechiae  seen  in  Fig.  62 
at  the  angles  of  the  coloboma.     Some  of  these  openings  were 


Fig.  64.— Oblique  Incision,  Too  High.    Lower  Leaflet  not 

Retracted.     (Eleven  days  after  operation.) 

a.  Cortex. 

defective  from  being  too  highly  placed  (Fig.  61).  The  short 
incision  or  tear  was  made  either  with  the  point  of  the  cystitome 
entangled  in  blood-clot,  as  already  mentioned,  or  with  blunt 


Fig.  65. — Narrow  Slit,  with  Adhesions  to  Posterior  Capsule 
producing  Transverse  Folds.  (Sixteen  days  after  operation.) 
a.  Cortex. 

point  sliding  over  the  surface  of  the  membrane  a  little  before 
engaging  in  it,  or  possibly  the  eye  was  unsteady  and  the  instru- 
ment not  introduced  far  enough  within  it.  Fig.  63  shows  a 
minor  degree  of  defect,  and  Figs,  65  and  66  a  more  marked 
degree  from  inelasticity  of  the  capsule,  the  edges  of  the  slit 


Description  of  the  Operation  109 

having  come  nearly  into  apposition.  This  was  most  often 
seen  after  operation  for  Morgagnian  cataract  with  punctate 
capsular  opacity.  Fig.  67  shows  also  a  narrow  slit,  the  margins 
having  possibly  become  drawn  together  by  contracting  blood- 
clot  and  lymph. 

These  narrow  apertures  are  the  only  ones  in  which  it  is 
evident  that  the  single  division  of  the  capsule  in  one  straight 
line  failed  to  provide  a  clear  space,  such  as  might  more  reason- 


FiG.  66.— Narrow  Slit  ending  in  an  Opaque  Band  below, 

APPARENTLY    FIBRINOUS.        MARKED    FOLDING    OF    CAPSULE. 
(Twelve  days  after  operation.) 

n.  Cortex. 

ably  have  been  expected  from  complex  or  multiple  division. 
In  rare  cases  also  of  tough  capsule  the  simple  straight  incision, 
insufficiently  widened  by  the  cystitome,  resisted  appreciably 
the  exit  of  the  lens  during  operation. 

Figs.  81  and  82  show  very  large  capsular  openings.  In  other 
cases  no  anterior  capsule  could  be  seen  ;  either  it  was  perfectly 
transparent  and  colourless,  or  it  had  retracted  so  completely  as 
to  be  hidden  by  the  iris,  even  though  the  pupil  was  dilated. 


Fig.  67. — Narrow  Slit  occupied  by  Fibrinous  Deposit,  form- 
ing A  Band  of  Opacity.  Much  Folding  of  Capsule. 
(Twenty-three  days  after  operation.) 

It  was  very  rarely  that  we  were  able  to  detect  any  incarcera- 
tion of  capsule  in  the  wound  or  adhesion  to  it — so  rarely  that 
the  mode  of  opening  the  capsule  could  scarcely  be  blamed.  In 
eyes  with  'vitreous  tension'  and  after  prolapse  of  vitreous 
there  must  at  times  be  some  impaction  of  the  capsule.  Becker 
has  shown  that  entanglement  of  points  of  capsule  is  not  always 
recognizable  clinically ;  but  such  cases  are  the  least  likely  to 
give  rise  to  trouble,  especially  when  the  site  of  entanglement  is 
covered  with  a  conjunctival  flap.     If,  then,  our  simple  division 


no  Cataract  Extraction 

of  the  capsule  predisposed  to  impaction,  the  predisposition  was 
evidently  overcome  by  replacement  of  the  iris  at  the  close  of 
the  operation  and  by  its  retention  in  position  by  an  active  and 
nearly  complete  sphincter  muscle. 

Speaking  generally,  the  question  of  the  precise  scheme 
of  capsulotomy  to  be  adopted  has  lost  much  of  its 
importance  since  the  early  treatment  of  after-cataract 
has  become  so  safe  and  effective  (see  later).  Still,  it  is 
doubtless  advisable  to  avoid  unnecessary  supplementary 
treatment,  and  with  this  object  the  opening  in  the  anterior 
capsule  should  extend  well  below  the  centre  of  the  pupil. 

In  simple  extraction  long  incisions  are  not  quite  so 
readily  made,  and  are  generally  replaced  by  movement  of 
the  point  of  the  instrument  in  more  than  one  direction. 
The  iris  above  should  serve  to  prevent  tags  of  capsule 
from  forming  adhesions  to  the  wound,  though  apparently 
it  has  not  always  done  so. 

Various  incisions  have  been  planned  by  numerous  operators, 
many  of  them  probably  very  imperfectly  carried  out.  Von  Arlt 
tried  to  make  a  V-shaped  division  of  the  capsule  with  a  sharp 
hook.  Von  Graefe  also  at  one  time  aimed  at  a  V-shaped 
opening  ;  later  (1870)  he  attempted  to  outline  a  large  square  in 
the  centre  of  the  membrane.  Weber  (1867)  made  two  hori- 
zontal tears  with  a  double  hook.  Czermak,  by  two  horizontal 
tears  in  opposite  directions,  aimed  at  the  formation  of  two 
flaps,  one  with  base  inwards,  the  other  with  base  outwards. 
"  Scratching  "  the  centre  of  the  capsule  in  different  directions 
has  been  the  method  of  many  surgeons.  Knapp  objects  to 
this,  as  especially  productive  of  small  shreds  of  capsule  likely 
to  unite  with  the  border  of  the  iris.  The  formation  of  adhesions 
is  favoured  by  the  numerous  minute  ruptures  of  the  iris  which 
occur  during  the  passage  of  the  lens  in  simple  extraction. 

Many  surgeons  have  used  slightly  curved  needles  for 
dividing  the  membrane.  The  Moorfields  pattern  cystitome  is 
shown  in  Fig.  25.     Hess  uses  cutting  forceps. 

L.  Miiller*  performs  the  capsulotomy  before  the  iridectomy 

-  Kl.  Mbl.f.  A.,  (1902)  xli,  358. 


Description  of  the  Operation  1 1 1 

in  order  that  the  upper  part  of  the  capsule  may  become  a  Httle 
folded  up  behind  the  iris,  and  thus  kept  away  from  the  wound. 
The  consideration  of  other  modes  of  opening  the  capsule  is 
relegated  to  Chapter  IV,  either  because  the  methods  are  not 
very  commonly  practised,  or  because  their  consideration  comes 
better  after  the  description  of  simple  extraction. 

The  toughened,  thickened,  and  opaque  capsules  of  some 
overripe  cataracts  demand  special  consideration. 

In  Morgagnian  cataracts,  especially  those  with  opaque 
capsules,  the  incision  must  be  made  with  an  unusually 
quick  movement,  and  the  point  of  the  cystitome  must  be 
sharp.  Otherwise  the  soft,  but  frequently  tough,  sac  of 
fluid  may  be  merely  indented  by  the  instrument,  and 
perhaps  pulled  about  by  it.  Or,  more  frequently,  a  small, 
insufficient  puncture  is  made.  This  is  because  the  rapidly 
emptying  sac  recedes  from  the  cutting  point  quite  early. 
Fearing  lest  this  may  take  place,  some  slight  attempt 
may  be  made  to  enlarge  the  aperture  by  movements  of 
the  cystitome  in  various  directions  while  still  some  fluid 
remains  within  the  sac.  But  if  the  capsule  be  opaque, 
this  attempt  is  often  unsuccessful.  Any  prolonged  use  of 
the  instrument  might  lead  to  puncture  of  the  posterior 
capsule  unless  the  nucleus  were  sufficiently  large  to  protect 
it,  and  free  movement  might,  by  pulling  on  the  tough 
capsule,  rupture  the  suspensory  ligament.  Because  of 
the  difficulty  experienced  in  enlarging  a  small  aperture, 
it  is  well  always  to  make  the  primary  cut  in  a  Morgagnian 
capsule  horizontal.*  The  opening  often  has  to  be  finally 
expanded,  with  trouble  and  some  slight  risk,  by  the  escape 
of  the  imprisoned  nucleus,  forced  out  by  continued  pres- 
sure and  counter-pressure  upon  the  globe.     And  this  is 

*  Knapp's  "peripherics  plitting"'  above  (see  Chapter  IV)  is  especially 
applicable  to  Morgagnian  cataracts,  except  in  that  the  later  discission 
of  these  inelastic  capsules  required  for  visual  purposes  sometimes 
provides  only  a  narrow  opening. 


1 1 2  Cataract  Extraction 

least  easily  accomplished  if  the  small  puncture  be  situated 
below.  For  then  the  nucleus  tends  to  slip  upwards 
away  from  the  opening  whenever  pressure  is  placed  upon 
the  eye. 

The  dense,  indivisible  central  opaque  plaque  of  some 
overripe,  generally  discoid,  cataracts  commonly  requires 
removal  by  the  use  of  both  cystitome  and  forceps.  Intra- 
capsular extraction  of  the  lens  may  be  preferred  in  quiet 
patients  by  many  surgeons.  But  I  believe  that  the  safest 
procedure  is  the  most  conservative.  The  capsule  is  first 
scratched  through  below  the  patch.*  If  the  latter  be 
then  hooked  up  by  the  tooth  of  the  cystitome,  the  mem- 
brane on  either  side  is  partly  torn.  The  patch  may  then 
be  readily  seized  with  iris  forceps,  and,  if  the  remainder 
of  the  capsule  be  nearly  normal,  slowly  withdrawn.  The 
tearing  away  of  the  central  portion  of  capsule  is  much 
more  likely  to  be  successful  at  this  stage  than  later,  since 
the  lens  in  situ  affords  a  certain  amount  of  resistance  to 
the  pull  of  the  forceps.  Should,  however,  the  surrounding 
capsule  be  also  somewhat  thickened  and  opaque,  indi- 
cating the  probability  of  extension  of  opacity  to  more  or 
less  of  the  posterior  capsule  also,  the  membrane  is  likely 
to  prove  more  resistant  than  the  zonule  below.  To  avoid 
rupturing  t  the  zonule  in  these  cases  the  pull  of  the 
forceps  must  be  light,  and  must  be  given  up  as  soon  as 
a  sufficient  opening  has  been  made  for  the  expulsion  of 
the  lens.  The  extraction  of  the  opaque  capsule  as  a 
whole  may  then  easily  be  accomplished  at  the  close  of  the 
operation,  after  the  removal  of  the  speculum. 

*  Snellen  recommends  for  this  purpose  a  fine  round  needle,  the 
extreme  point  of  which  is  bent  over  at  an  angle  of  90  degrees  (see 
Haab's  '  Operative  Ophthalmology,'  p.  150). 

t  Should  this  accident  happen,  the  lens  and  capsule  must  be 
extracted  together  by  the  pull  of  the  forceps,  aided  by  an  upward  push 
with  curette  or  hook  on  the  surface  of  the  cornea. 


Description  of  the  Operation  1 1 3 

The  same  practice  may  be  adopted  for  some  very  over- 
ripe juvenile  cataracts,  mainly  capsular,  in  which  there 
may  be  an  anterior  patch  of  great  density.  The  extrac- 
tion of  this  layer  of  membrane  is  much  facilitated  and 
freed  from  risk  by  preliminary  cuts  below  and  at  its  side. 

There  is  still  another  form  of  cataract  requiring  special 
mention — the  previously  Morgagnian  cataract,  with  all  the 
fluid  absorbed,  consisting  merely  of  the  nucleus  in  a 
shrunken  sac,  the  capsule  often  quite  transparent,  and  the 
whole  lens  being  possibly  more  or  less  tremulous.  The 
nature  of  the  cataract  may  have  passed  unrecognized  until 
the  iridectomy  has  revealed  a  dark  clear  space  above  the 
shrunken  nucleus.  I  believe  the  safest  procedure  is  to 
begin  in  the  ordinary  way. 

A  cautious  attempt  at  capsulotomy  is  made  with  a 
sharp  cystitome  passed  in  from  the  side.  Here  the  iris 
intervening  between  the  cystitome  and  the  zonule  and 
loose  capsule  prevents  injury  to  the  latter.  If  the  in- 
strument were  passed  down  from  above  at  the  site  of 
the  coloboma,  its  point  might  readily  tear  or  puncture 
the  thin  membranes  which  alone  cover  the  vitreous 
in  this  situation.  An  attempt  is  made  to  scratch  through 
the  anterior  capsule  where  it  overlies  the  nucleus 
with  the  tooth  directed  only  a  little  backwards.  In  a 
quiet  patient  it  appears  to  be  almost  immaterial  whether 
this  attempt  is  successful  or  not.  More  often  I  think  it 
fails,  and  instead  of  the  capsule  giving  way,  the  suspensory 
ligament  below,  and  probably  more  or  less  at  the  sides 
also,  is  torn.  This  greatly  facilitates  expulsion  of  the 
lens  in  its  capsule.  Sometimes  a  mere  puncture  is  made 
in  the  capsule,  and  the  zonule  torn  also.  One  cannot  be 
quite  sure  what  has  happened  sometimes  until  an  examina- 
tion of  the  expressed  nucleus  shows  whether  it  has  escaped 
with  or  without  the  capsule.     Should  the  opening  in  the 

8 


1 1 4  Cataract  Extraction 

capsule  have  proved  adequate  for  the  exit  of  the  nucleus 
alone,  the  untorn  posterior  capsule  and  zonule  may  be 
of  great  advantage  in  an  excitable  patient.  The  intact 
diaphragm  may  serve  to  prevent  a  large  loss  of  vitreous. 


THE    DELIVERY    OF   THE    LENS. 

This  is  the  step  of  the  operation  in  which  restraint  and 
patience  on  the  part  of  the  operator  are  most  needed. 
The  lens  is  expelled  from  the  globe  mainly  by  instrumental 
pressure  applied  about  the  lov/er  border  of  the  cornea. 
By  this  means  the  intraocular  pressure  may  be  increased, 
the  wound  forced  open,  and  the  lens  tilted  to  present  its 
margin  in  the  wound,  while  the  localized  indentation  of 
the  globe  helps  directly  to  displace  the  lens  upwards. 
Continuance  of  the  pressure  tends  to  cause  the  lens  to 
move  slowly  upwards,  pushing  the  pillars  of  the  coloboma 
to  either  side,  to  enter  and  to  fill  the  wound.  The  further 
movement  required  to  complete  the  passage  of  the  lens 
out  of  the  eye  is  facilitated  by  movement  of  the  expressing 
instrument  upwards  over  the  cornea,  following  the  lens, 
and  more  especially  by  the  distribution  of  the  pressure  and 
indentation  to  either  side  as  well  as  directly  below  the 
lens.  Further,  the  hard  coat  of  the  eye  is  sufficiently 
flexible  to  allow  of  the  expressor  being  sometimes  used  to 
actually  push  the  lens  substance  upwards.  The  effect  of 
repeated  light  upward  strokes  on  the  surface  of  the  cornea 
is  particularly  noticeable  upon  the  nuclei  of  Morgagnian 
cataracts,  and  rather  less  so  upon  some  small  thin  lenses, 
and  upon  cortical  matter  remaining  after  the  bulk  of  the 
lens  has  escaped. 

Whether  the  hook  or  the  spoon  be  selected  (see  p.  36),  it  is 
applied  at  first  obliquely,  so  that  only  a  portion  of  the 
curve  is  in  use,  the  handle  and  stem  inclining  upwards 


Description  of  the  Operation  1 1 5 

and  somewhat  forwards.  The  angle  at  which  the  instru- 
ment is  used  is  altered  later,  according  as  one  may  need 
to  utilize  the  two  ends  of  the  curve  for  lateral  pressure  or 
the  convexity  for  pushing  strokes  upon  the  cornea. 

The  expressor  is  held  in  the  right  hand,  and  assistance 
is  rendered  in  one  or  several  ways  by  the  operator's  other 
hand.  In  combined  extraction  the  left  hand  can  be 
most  advantageously  employed  with  fixation  forceps,  used 
not  only  directly  to  aid  in  expression,  but  also  for  sub- 
sidiary small  manipulations  more  or  less  helpful.  The 
patient  should  still  keep  the  eye  turned  somewhat  down- 
ward, unless  the  eyeball  be  unusually  prominent. 

For  all  distinctly  unripe  cataracts  it  is,  I  believe,  impor- 
tant, and  for  most  lenses  with  soft  cortex  advantageous, 
to  seize  the  conjunctiva  below  the  cornea  with  the 
forceps*  as  the  first  step.  By  a  downward  pull,  together 
with  very  slight  backward  pressure  of  the  forceps,  the 
wound  is  made  to  gape  a  little.  The  lower  lip  of  the 
incision  is  displaced  forwards,  and  the  cornea  somewhat 
flattened,  so  that  its  posterior  surface  may  serve  as  an 
inclined  plane  to  direct  the  lens  into  the  gap  above,  while 
any  pressure  exerted  by  the  forceps  quite  below  the  lens, 
indenting  the  globe  there,  must  tend  to  displace  the  lens 
upwards.  As  soon  as  the  section  is  found  to  open  evenly 
thus,  the  expressing  instrument  is  laid  upon  the  lower 
edge  of  the  cornea  with  gradual  pressure  backwards.  In 
dealing  with  unripe  cataracts  the  use  of  the  two  instru- 
ments should  usually  be  continued  together  thus  until  the 
lens   has  begun    to  move  upwards  into  the  wound.     In 

*  The  grip  of  the  forceps  is  at  least  temporarily  released  on  any 
involuntary  straining  of  the  globe  upwards.  And  this  use  of  the 
forceps  is  dispensed  with  altogether  in  tense  eyes,  in  which  the  lens  is 
pressed  forwards,  and  in  the  case  of  individuals  with  tense  eyelids,, 
which  are  not  drawn  forward  by  the  speculum  sufficiently  from  the 
globe. 

8—2 


1 1 6  Cataract  Extraction 

other  cases  the  forceps  may  be  removed  as  soon  as  the 
pressure  of  the  hook  (or  spoon)  suffices  to  keep  the 
incision  open. 

For  lenses  with  firm  cortex,  especially  overripe  cata- 
racts, thinned  particularly  about  the  equator,  the  above 
manipulation  is  not  quite  so  well  suited.  The  fixation 
forceps  may  be  utilized  otherwise.  These  lenses  are  very 
apt  to  slip  upwards  behind  the  wound  instead  of  present- 
ing in  it.  It  is  usually  better  in  dealing  with  them  to 
begin  at  once  with  backward  pressure  at  or  a  little  above 
the  lower  edge  of  the  cornea,  while  the  conjunctival  flap 
is  seized  by  the  forceps  and  the  wound  thereby  opened  for 
a  moment.  One  is  thus  enabled  to  see  whether  the  lens 
is  in  correct  position.  Its  upper  border  should  be  readily 
seen  tilted  a  little  forward  by  the  pressure  below,  and 
ready  to  engage  in  the  wound.  If  the  equator  of  the  lens 
is  not  thus  seen,  it  is  practically  certain  to  have  become 
a  little  displaced  upwards  behind  the  scleral  lip  of  the 
wound,  possibly  having  been  pulled  up  by  the  cystitome 
during  the  capsulotomy. 

This  opening  of  the  wound  by  the  forceps  is  often  of 
some  slight  direct  advantage,  since  there  may  be  already 
a  tendency  to  gluing  of  the  conjunctival  flap  down  by 
means  of  blood-clot,  particularly  in  cases  where  there  has 
been  some  slight  delay  at  any  time  after  the  completion 
of  the  section.  This  pulling  of  the  corneal  flap  forwards 
may  be  repeated  at  any  time  as  a  possible  aid  to  the  exit  of 
the  lens.  (But  in  operations  where  the  forceps  have  just 
been  used  upon  the  conjunctiva  below  the  cornea,  possible 
doubts  concerning  the  sterility  of  the  conjunctival  surface 
suggest  that  the  forceps  should  not  be  applied  about  the 
wound  margin  without  being  cleansed  upon  the  lint  in  the 
bowl  of  lotion  kept  at  hand.) 

If  it  is  found  that  the  lens  margin  has  slipped  upwards 


Description  of  the  Operation  1 1 7 

behind  the  wound,  or  tends  to  do  so,  it  may  be  easily 
pushed  down  again  by  the  convexity  of  the  hook  or  the 
edge  of  the  spoon  applied  on  the  corneal  surface  close 
below  the  wound.  There  is  usually  no  need  to  reintroduce 
the  cystitome  within  the  wound  for  this  purpose.  The 
upper  lip  of  the  wound  is  then  depressed  by  running  the 
closed  ends  of  the  forceps  lightly  along  the  sclerotic  above 
the  wound  from  end  to  end,  while  the  upper  edge  of  the 
lens  is  tilted  forward  by  the  application  of  the  convexity 
of  the  hook  on  the  lower  part  of  the  cornea.  As  soon  as 
the  lens  border  presents  in  the  wound  there  is  no  longer 
need  to  keep  up  the  depression  of  the  sclera. 

This  upward  displacement  may  not  be  always  easily 
recognizable  in  operating  without  a  conjunctival  flap,  and 
therefore  without  the  means  of  opening  the  wound  to  look 
within.  It  may  be  suspected  when  pressure  applied  to 
the  lower  part  of  the  cornea  has  little  effect  upon  the 
wound — when  the  tilting  forward  of  the  lower  lip  of  the 
incision  is  very  slight  and  more  or  less  uneven. 

Should  the  source  of  trouble  pass  unrecognized,  and 
should  reposition  not  be  effected,  an  attempt  at  introduc- 
tion of  a  loop  or  spoon  behind  the  lens  may  cause  the 
latter  to  revolve  on  its  horizontal  axis,  the  lower  edge 
coming  forwards  and  upwards  to  escape  first,  and  there 
is  likely  to  be  loss  of  vitreous. 

Should  lateral  movements  have  been  practised  with  the 
cystitome,  some  slight  lateral  displacement  of  the  lens 
may  have  been  caused.  The  displacement  should  be 
corrected  by  pushing  strokes  over  the  corneal  circum- 
ference before  the  delivery  of  the  lens  is  attempted. 

Whatever  be  the  variety  of  the  lens,  as  soon  as  its 
equator  has  engaged  in  the  wound  the  forceps  may 
further  directly  assist  in  moving  the  lens  upwards  by 
light  pressure,  or  rather  counter-pressure,  at  the  left  lower 


ii8 


Cataract  Extraction 


margin  of  the  cornea,  while  the  hook  or  spoon  is  apphed, 
with  more  or  less  rocking  movement,  at  the  lower  and  at 
the  lower  and  right  margin.  Either  the  closed  ends  of  the 
forceps  may  be  used  (see  Fig.  68)  or,  in  operating  on  the 
left  eye,  the  flat  of  the  blades  applied  obliquely.     The 


Fig.  68. — Expression  of  the  Lens. 

The  nucleus  is  seen  already  lying  on  the  outer  canthus,  and  cortex 
is  issuing  from  the  wound. 

weight  of  the  two  instruments  distributed  thus  over  a 
wide  area  below  appears  to  combine  the  greatest  efficiency 
with  safety.  After  the  lens  has  slowly  passed  upwards, 
occupying  the  wound,  the  hook  or  spoon  follows,  pressing, 
if  need  be,  alternately  on  either  side.  The  bulk  of  the 
lens  may  finally  be  caught  by  the  forceps  as  it  escapes,  or 


Description  of  the  Operation  1 19 

may  be  lifted  out  of  the  wound  by  the  forceps  (or  if  the 
spoon  be  used,  the  lens  is  received  and  removed  in  its 
bowl). 

Unless  the  sclero-corneal  section  be  of  full  size,  the 
sharp  edge  of  a  large  firm  lens  may  carry  the  pillars  of 
the  coloboma  folded  over  it  into  the  wound,  nipping  the 
iris  between  lens  and  cornea.  But  we  have  seen  very  little 
of  this,  owing  to  the  regular  use  of  a  sufficiently  large 
incision,  and  perhaps  also  owing  to  the  making  of  a  deep 
coloboma  up  to  the  base  of  the  iris.  In  eyes  with  marked 
vitreous  tension,  however  (see  below),  it  is  not  always 
possible  to  avoid  the  entrance  of  iris  into  the  angles  of 
the  wound. 

The  above  description  of  lens  expulsion  differs  from  the 
practice  usually  followed,  which  is  the  same  in  combined 
extraction  as  in  simple  extraction.  Continuous  counter- 
pressure  above  with  spatula  or  curette  is  combined  with 
pressure  below.  The  less  peripheral  the  section,  the  more 
necessary  is  depression  of  the  upper  lip  of  the  incision  to 
guide  the  lens  forward.  But  it  is  not  needed,  as  in  simple 
extraction,  for  drawing  the  iris  backwards.  And  the  path 
of  the  lens  is  more  directly  upwards.  Acute  watchfulness 
is  required  in  the  use  of  counter-pressure  above,  lest  by 
sudden  upward  movement  of  the  eye  the  instrument  be 
carried  into  the  wound. 

For  fully  ripe  cataracts  the  exact  method  of  expulsion 
matters  comparatively  little  in  the  combined  operation. 
But  in  expressing  cataracts  in  the  least  degree  unripe  it  is 
important  that  no  trace  of  sticky  cortex  be  left  in  the 
lower  periphery.  It  must  be  displaced  up  with  the  body  of 
the  lens,  otherwise  later  efforts  to  remove  it  will  probably 
fail.  And  for  this  purpose  I  have  found  the  above  procedure 
most  effective.  But  it  is  essential  that  the  beginning  of  the 
lens  movement  shall  be  slow  and  gradual. 


I20  Cataract  Extraction 

A  little  soft  cortex  may  be  stripped  off  the  back  of  the 
lens  by  the  undepressed  scleral  lip  of  the  wound,  but  lens 
matter  left  lying  thus  near  the  wound  is  comparatively 
easily  dislodged  afterwards.  Cortex  left  below  has  always 
appeared  to  me  particularly  difficult  to  move.  It  is  farthest 
away  from  the  influence  of  the  stream  from  the  irrigator, 
unless  the  nozzle  be  introduced  to  a  dangerous  distance 
within  the  anterior  chamber.  And  it  is  less  responsive  to 
pressure  applied  upon  the  eye  than  lens  substance  which 
has  already  been  more  or  less  displaced  from  its  original 
bed. 

The  earlier  operators  delivered  the  lens  by  finger  pressure 
through  the  lids.  With  the  lower  section  spontaneous  delivery 
was  not  uncommon  when  the  patient  looked  upwards.  Assist- 
ance was  given  by  pressure  below  the  wound  through  the  lower 
lid,  and  light  counter-pressure  above.  The  direct  utilization 
of  the  sense  of  touch  is  an  advantage  which  is  lost  in  instru- 
mental expression.  But  the  great  objection  to  this  use  of  the 
lids  is  that  in  unexpected  movements  of  the  eye  the  margin  of 
the  open  wound  is  liable  to  sweep  along  the  lid  surfaces  and 
borders,  and  thus  possibly  to  become  fouled  by  material  con- 
taining pathogenic  organisms.  Contact  with  the  lid  borders  is 
especially  to  be  feared.  Not  only  are  they  insusceptible  of 
complete  sterilization,  but  they  may  become  more  or  less  coated 
with  Meibomian  secretion,  squeezed  out  by  the  pressure  of  the 
fingers  upon  the  lid.  Many  well  known  surgeons  still  employ 
pressure  through  the  border  of  the  lower  lid  to  express  the 
lens.  The  upper  lid  is  elevated  by  retractor  or  by  the  finger, 
and  counter-pressure  above  generally  by  spatula  or  spoon. 
With  an  upper  section  there  is  not  so  much  risk  of  direct  soiling 
of  the  wound  by  the  lid  borders  as  with  the  lower  section.  But 
the  danger  incurred  of  vitreous  expulsion  by  contraction  of  the 
lower  lid  upon  the  globe  seems  needlessly  great.  Trousseau 
presses  out  the  lens  by  the  back  of  the  blade  of  the  Graefe's 
knife,  occasionally  aided  by  counter-pressure  applied  by  the 
edge  of  the  upper  lid. 

Von  Graefe  tried  various  manoeuvres  to  expel  the  lens  through 
his  comparatively  narrow  wound.     At  one  time  he  attempted 


Description  of  the  Operation  121 

to  draw  the  lens  upwards  by  movements  of  the  spoon  over  the 
sclerotic  from  each  end  of  the  section.  He  also  utilized  the 
downward  pull  of  fixation  forceps,  spoon  pressure  at  the  lower 
corneal  margin,  and  upward  strokes  over  the  corneal  surface. 

In  the  delivery  of  the  lens  two  chief  points  are  to  be 
borne  in  mind :  firstly,  to  expel  the  lens  as  nearly  as  pos- 
sible whole,  in  one  mass ;  and  secondly,  and  much  more 
important,  to  ever  avoid  rupture  of  suspensory  ligament,  by 
too  heavy  or  improperly  applied  force.  It  cannot  be  too 
strongly  insisted  upon  that  pressure  and  manipulation  for 
the  delivery  of  lens  or  of  cortical  remains  need  never  be 
other  than  very  gentle,  if  properly  directed,  and  if  the 
sources  of  difficulty  are  sought  out.  Heavier  pressure  is 
much  more  likely  to  rupture  the  zonule  or  posterior 
capsule  than  to  move  lens  matter  which  has  resisted  lighter 
efforts.  Very  slow  early  movement  of  the  lens  is  not 
always  a  sufficient  guarantee  that  unsafe  force  is  not  being 
used,  though,  on  the  other  hand,  rapid  early  movement 
may  be  generally  accepted  as  evidence  of  the  employment 
of  unnecessarily  great,  and  therefore  dangerous,  pressure. 
While  the  exercise  of  patience  and  restraint  is  vastly  im- 
portant, it  cannot  be  held  that  any  great  display  of  skill 
or  dexterity  is  needed. 

There  are  other  occasional  difficulties  in  the  delivery  of 
the  lens  in  addition  to  those  already  mentioned,  \'\z.,  dis- 
placement of  the  lens  upwards  or  to  the  side,  and  adhesion 
of  the  conjunctival  flap  and  wound  margins  by  means  of 
blood-clot.     They  occur  thus  : 

I.  There  may  be  trouble  from  too  small  a  section.  This 
can  only  happen  with  a  badly  cut  section,  the  incision  at 
the  deep  surface  of  the  cornea  being  much  smaller  than  at 
the  external  surface,  or  from  the  use  of  a  short  flap  in 
extracting  a  lens  with  large  hard  nucleus.     One  may  be 


122  Cataract  Extraction 

tempted  to  employ  rather  heavy  pressure,  and  so  cause 
loss  of  vitreous.  For  the  enlargement  of  the  w^ound 
Stevens'  curved  tenotomy  scissors  are  well  suited.  I  think 
it  is  easier  to  cut  with  scissors  than  with  a  blunt-ended 
'  secondary '  knife.  Melville  Black  (Denver)  uses  a  probe- 
pointed  Graefe's  knife. 

2.  The  capsule  may  be  intact  or  insufficiently  opened, 
(a)  One  is  naturally  alive  to  this  possibility  when  one 
has  used  the  cystitome  with  its  point  buried  in  blood-clot. 
The  lens  is  found  to  move  readily,  but  to  a  very  limited 
extent,  whenever  pressure  is  placed  upon  the  eye.  It 
then  stops  dead.  A  second  use  of  the  cystitome  generally 
puts  matters  right. 

(6)  In  Morgagnian  cataracts  the  making  of  a  mere 
puncture,  insufficient  even  for  the  passage  of  the  smallest 
nucleus,  is  to  be  frequently  expected,  especially  with  the 
more  opaque  (dotted)  capsules.  Any  trouble  in  expelling 
the  nucleus  of  such  a  lens  may  unerringly  be  attributed  to 
this  source.  Persistent  cautious  attempts  at  expulsion  are 
usually  successful  in  enlarging  the  aperture  sufficiently 
after  a  time.  But  it  is  a  tedious  process,  and  at  the  end 
one  finds  often  that  the  capsule  has  been  more  or  less 
displaced  upwards,  though  whether  the  tearing  of  the 
suspensory  ligament  which  this  reveals  has  occurred  more 
particularly  during  the  capsulotomy  or  during  the  expres- 
sion may  remain  a  matter  of  conjecture.  If  the  capsule 
has  been  so  much  displaced  as  to  lie  folded  close  to  the 
wound,  and  possibly  in  all  cases  when  displacement  can 
be  made  out — i.e.,  when  the  lower  limit  of  the  capsule  can 
be  seen — its  removal  with  iris  forceps  at  the  close  of  the 
operation  is  indicated,  lest  the  dangerous  complication,  in- 
carceration of  capsule  in  the  wound,  should  follow.  Occa- 
sionally the  enlargement  of  the  capsular  opening  under 
pressure  does  not  take  place,  and  the  nucleus  is  found  to 


Description  of  the  Operation  123 

come  out  enveloped  in  the  capsule.  In  any  case  the  mode 
of  expulsion  of  the  nucleus  of  a  Morgagnian  cataract  is 
quite  different  from  that  of  a  complete  lens.  It  is  pushed 
upwards  by  repeated  light  strokes  with  the  convexity  of  the 
hook  applied  to  the  cornea  below  it.  The  strokes  being 
directed  against  the  lower  margin  of  the  nucleus,  the  latter 
readily  slides  upwards  as  far  as  the  enclosing  capsule 
permits.  When  its  upper  margin  has  arrived  close  to  the 
wound  the  upper  lip  of  the  incision  is  depressed  with  the 
fixation  forceps,  or  preferably  with  spoon  or  loop,  to  guide 
the  presenting  edge  of  the  nucleus  forward.  But  the 
pressure  applied  with  either  instrument,  above  or  below, 
must  be  very  moderate.  And  as  soon  as  the  nucleus  is 
found  to  be  held  rather  firmly  by  tough  capsule,  the  pre- 
caution is  taken  of  substituting  Desmarres'  retractor  for 
the  stop-speculum.  A  second  attempt  with  the  cystitome 
introduced  from  the  side,  to  widen  the  capsular  opening,* 
may  succeed  in  this,  or  may  assist  in  intracapsular  delivery 
by  tearing  the  zonule  below. 

The  same  pushing  strokes  are  needed  for  the  expulsion ' 
of  overripe  cataracts,  formerly  Morgagnian,  consisting  of 
nucleus  and  capsule  only.  Here,  as  already  stated,  if  the 
capsule  be  transparent,  one  has  no  means  of  judging 
whether  the  capsulotomy  has  failed  completely  or  not, 
except  by  results. 

(c)  One  must  expect  a  little  trouble  with  very  opaque 
capsules,  presenting  the  large  dense  anterior  plaque.  But  if 
the   opening  has  been   made  with   a  sharp   instrument, 

*  Care  must  be  taken  that  the  nucleus  is  behind  the  point  of  the 
cystitome  guarding  the  posterior  capsule.  In  one  case  I  punctured 
the  posterior  capsule  in  an  attempt  to  widen  the  opening,  and,  the 
patient  being  nervous  and  unable  to  keep  his  eye  turned  down,  I 
preferred  to  leave  matters  as  they  were  rather  than  to  incur  certain 
loss  of  vitreous  in  the  expulsion  of  the  nucleus.  The  latter  had 
become  displaced  laterally,  so  that  there  was  a  sufficient  aperture  for 


124  Cataract  Extraction 

and  enlarged  if  necessary  by  tearing,  the  shrunken  lens 
may  be  expected  to  come  through  piecemeal.  The 
expression  may  be  tedious,  since  the  capsule  as  a  whole 
may  be  too  tough  for  the  opening  to  stretch  or  enlarge 
easily.  Yet  less  pressure  is  required  than  would  have 
been  needed  for  intracapsular  expulsion,  as  is  shown  by 
the  preservation  of  the  zonule  intact.  There  is  generally 
a  broad  equatorial  rim  of  firm  cortex  which  may  need  to 
be  washed  out  in  sections. 

Should  the  zonule  have  been  torn  below  by  pull  by 
cystitome  or  forceps  on  the  dense  anterior  capsule — as 
shown  by  slight  displacement  of  the  shrunken  lens 
upwards — the  capsule  lying  in  the  wound  serves  as  a 
guide  to  the  lens  and  a  support  to  the  vitreous, 
preventing  disturbance  of  the  latter  under  moderate 
pressure.  The  capsule  may  be  dealt  with  afterwards 
(see  Chapter  IV). 

(d)  There  are  more  puzzling  cases  in  which  difficulty  is 
experienced  with  the  capsule  though  the  cataract  is  not 
overripe.  The  source  of  the  trouble  is  therefore  not 
readily  recognized.  Some  of  our  difficulties  have  been 
due  to  the  making  of  an  insufficient  opening  by  a  blunted 
cystitome  (damaged  by  numerous  heatings  in  the  flame). 
In  other  cases  the  capsule  has  been  seen  afterwards  to  be 
very  slightly  opaque,  though  this  was  not  clearly  recog- 
nizable while  the  lens  was  in  place,  and  the  trouble  was 
therefore  probably  due  to  rigidity  of  the  capsule.  Soft 
cortex  may  come  forward  freely  through  the  opening,  yet 
the  bulk  of  the  lens  is  persistently  held  back.  Or  if  the 
cortex  be  firmer,  continued  pressure  on  the  globe  may 
force  the  margin  of  the  lens  upwards  a  trifle  more  at  one 
point  than  elsewhere — i.e.,  at  the  site  of  the  partly  opened 
slit  in  the  capsule.  Finally,  if  the  cystitome  be  not  again 
introduced,  and  if  the  attempts  at  expulsion  be  continued, 


Description  of  the  Operation  125 

the  capsule  suddenly  gives  way,  and  the  lens  slips  upwards 
through  the  wound. 

3.  Firm  coherent  lenses  are  naturally  less  easy  of 
expression  than  those  with  soft  and  diffluent  cortex, 
though  they  are  more  likely  to  come  out  whole  or  nearly 
so.  Thin  discoid  lenses,  especially  the  smaller  ones,  are 
sometimes  singularly,  and  somewhat  unaccountably,  irre- 
sponsive to  pressure  put  upon  the  eye.  Care  must  be 
taken  to  avoid  making  the  sclero-corneal  incision  gape 
unnecessarily.  The  sharp  and  thin  upper  margin  of  the 
lens  may  be  seen  tilting  forwards  with  the  cornea,  and 
one  fears  for  the  stretched  zonule*  presenting  in  the 
wound.  A  second  insertion  of  the  cystitome  to  widen  the 
capsular  opening  does  not  mend  matters.  The  smaller 
lenses  must  be  patiently  worked  upwards  by  light,  jerky 
strokes  with  the  convexity  of  the  hook  or  spoon  over  the 
lower  part  of  the  cornea.  And  it  is  an  advantage  to  keep 
the  wound  a  little  opened  at  the  same  time,  either  by 
means  of  the  conjunctival  flap  gripped  by  the  fixation 
forceps,  or  by  a  downward  pull  on  the  conjunctiva  below 
the  cornea.  Larger  lenses  of  the  same  type  begin  to  move 
upward  slowly  under  continued  steady  pressure  on  both 
sides  at  the  lower  edge  of  the  cornea. 

4.  Difficulty  and  danger  may  arise  from  early  rupture  of 
zonule.  The  cases  are  at  once  divisible  into  two  main 
groups  according  as  vitreous  has,  or  has  not,  come  forward 
in  front  of  the  lens. 

(a)  Where  the  lens  has  not  sunk  backwards  into  the 

*  In  simple  extraction  of  these  lenses  there  appears  to.be  less  risk 
of  rupturing  the  zonule.  Owing  to  the  support  of  the  iris,  one 
appears  to  be  able  to  tilt  forward  the  cornea  to  any  extent  with 
impunity.  I  think  that  the  marked  difiference  in  the  proportion  of 
vitreous  losses  experienced  by  some  operators  {e.g.,  Drake  Brock- 
man  ;  see  Chapter  IV)  in  combined  and  in  simple  extraction,  must 
have  been  chiefly  in  operating  upon  these  lenses  with  tirm  cortex 
and  thinned  equatorial  portions. 


126  Cataract  Extraction 

vitreous,  there  is  frequently  a  fair  chance  of  finishing  with- 
out vitreous  accident,  or  without  increasing  the  vitreous 
loss  should  some  already  have  been  lost.  The  tear  in  the 
zonule  may  be  either  below  or  above  the  lens. 

Rupture  below  the  lens  is  much  the  least  likely  to  give 
trouble.  There  is  a  tendency  to  slight  displacement  of 
the  lens  upwards,  rendering  depression  of  the  upper 
margin  of  the  wound  imperative  before  expulsion  is 
attempted.  And  if  particular  care  be  not  taken,  vitreous 
may  follow  the  lens  into  the  wound.  But  other  cases  of 
slight  rupture  occur,  perhaps  from  the  pull  of  the  cystitome, 
without  one  being  made  aware  of  the  fact,  till  focal 
illumination  reveals  it  at  the  time  of  discharge  of  the 
patient. 

Rarely  the  pressure  or  pull  of  the  knife  in  completing 
the  section  may  have  been  such  as  to  rupture  the  sus- 
pensory ligament  above.  The  lens  may  have  been  seen  to 
slip  more  or  less  downwards.  If  vitreous  tends  to  protrude 
only  when  pressure  is  put  upon  the  eye,  none  having  yet 
been  lost,  and  if  the  displacement  of  the  lens  is  quite 
small  or  inappreciable,  capsulotomy  may  still  be  carefully 
performed  and  ordinary  expression  aimed  at,  because  the 
only  alternative — vectis  extraction  of  the  lens  in  its  capsule 
— is  certain  to  lead  to  considerable  loss  of  vitreous,  since 
the  lens  does  not  come  easily,  being  held  below.  On 
other  rare  occasions  the  rupture  may  have  been  due  to 
some  sudden  accidental  pressure  of  speculum  or  other 
instrument  upon  the  globe,  or  through  spasm  of  the 
orbicularis,  or  otherwise.  A  little  vitreous  may  have  been 
forced  out  of  the  wound,  and  yet  the  lips  of  the  wound 
may  have  come  together  again.  The  eye  may  be  '  slack,' 
and  there  may  be  no  apparent  tendency  to  further  loss  of 
the  humour.  The  same  practice  may  be  followed  here. 
The  scleral  lip  of  the  wound  must  be  well  depressed  with 


Description  of  the  Operation  127 

spoon  or  loop,  which  is  ready  to  be  sHpped  in  behind  the 
lens  in  case  of  necessity.  The  objection  to  the  capsul- 
otomy  in  these  cases  is  that  cortex  is  apt  to  be  left  behind. 
Little  or  no  attempt  can  be  made  to  extract  this  after  the 
bulk  of  the  lens  has  been  expelled.  Hence  the  practice 
is  limited  to  fully  ripe  cataracts,  in  which  trouble  with 
cortex  is  least  to  be  anticipated. 

In  cases  where  the  wound  is  distinctly  occupied  by  a 
prolapse  of  vitreous,  broad  or  narrow,  the  spoon  or  loop 
must  be  at  once  inserted  into  the  globe.  The  introduction 
of  the  instrument  is  always  done  in  fear  and  trembling. 
Some  degree  of  downwards  rotation  of  the  globe  (variable 
according  to  the  prominence  of  the  eye)  is  essential,  and 
one  is  placed  in  an  almost  hopeless  position  if  the  patient 
cannot  maintain  this  position  of  the  eyeball  with  some 
steadiness,  since  fixation  by  forceps  is  now  quite  out  of 
the  question.  (Possibly  further  instillation  of  cocain 
may  enable  a  troublesome  patient  to  keep  his  eye  more 
fixed.)  The  speculum  is  retained  if  the  lids  show  not  the 
least  tendency  to  contract ;  otherwise  Desmarres'  retractor 
and  finger  depression  are  substituted.  The  spoon,  held  in 
the  left  hand,  is  first  insinuated  only  behind  the  upper 
half  of  the  lens  to  serve  as  a  guide  and  support.  Pressure 
is  then  cautiously  applied  with  the  hook  or  tortoiseshell 
spoon  about  the  lower  margin  of  the  cornea  in  the  usual 
way,  and  the  lens  thus  delivered  between  the  two  instru- 
ments. But  should  the  lens  not  come  readily  thus,  and 
vitreous  be  escaping,  the  spoon  must  be  passed  down  as 
far  as  the  lower  margin  of  the  lens,  to  get  a  purchase  upon 
it  and  to  draw  it  upwards,  pressing  it  against  the  cornea. 
Even  so  assistance  may  sometimes  be  afforded  by  light 
pressure  with  the  additional  instrument  in  front  of  the 
cornea. 

(6)  In  other  cases  the  lens  is  obviously  displaced  more 


128  Cataract  Extraction 

or  less  backwards,  embedded  in  vitreous.  In  India  this 
dislocation  may  be  the  previous  work  of  a  vaid  or  hakim. 
Or  possibly,  in  a  diseased  eye,  the  depression  may  have 
taken  place  during  the  section  cutting.  We  have  here 
the  lens  in  its  capsule  to  deal  with.  In  still  other  cases  the 
faulty  position  may  be  due  to  ill-advised  pressure  with  the 
cystitome,  or  to  accidental  displacement  by  the  same  or 
other  instrument  in  a  restless  eye.  And  the  capsulotomy 
having  been  performed,  cortical  matter  may  possibly  have 
escaped  out  of  the  capsule,  mixing  with  the  surrounding 
vitreous,  where  it  must  usually  be  left.  It  may  prove 
difficult  to  pass  the  loop  over  the  upper  edge  of  the  lens. 
Preliminary  depression  of  the  upper  wound  margin  by  the 
instrument  must  be  tried.  It  may  still  serve  to  direct  the 
lens  margin  into  the  wound,  and  to  enable  the  spoon  to  slip 
in  behind  it.  If  it  fails,  the  loop  must  be  directed  within 
the  wound,  at  first  directly  backwards. 

The  attempt  may  displace  the  lens  bodily  downwards 
and  backwards,  to  lie  loosely  in  the  vitreous  humour.  In 
such  a  case  it  is  recommended  to  remove  the  speculum 
and  to  wait  until  the  lens  comes  up  again  into  the 
pupillary  area,  and  then  to  extract  it  with  the  loop.  This 
reposition  may  take  place  within  half  an  hour,  or  not  for 
some  weeks,  if  at  all,  necessitating  in  some  cases  reopen- 
ing of  the  closed  wound  or  the  making  of  a  fresh  incision.* 
I  have  preferred  to  follow  and  remove  the  lens,  even  though 
vitreous  were  escaping  through  theopen  wound.f  In  other 
cases  the  spoon  or  loop  presses  the  upper  margin  only  of  the 
lens  backwards,  causing  the  lens  to  rotate  on  its  horizontal 

*  Hoor,  Zeitsch.  f. pr.  A.,  1900,  p.  19. 

t  Twice  I  have  lost  the  lens  in  the  vitreous  permanently — once  in  a 
child  and  once  in  an  adult.  In  the  case  of  the  adult  the  nucleus  of 
the  lens  only  was  thus  lost,  and  the  patient  went  out  of  hospital  with 
fair  vision,  after  a  'needHng'  of  a  thin  inflammatory  pupillary  mem- 
brane. 


Description  of  the  Operation  129 

axis,  the  lower  margin  coming   forward    and  upward  to 
present  in  the  wound. 

5.  One  must  expect  considerable  trouble  at  times 
simply  from  the  patient's  stock  of  self-command  having 
become  exhausted  for  the  time  being.  One  can  get  the 
lens  margin  to  present  in  the  wound  fairly  easily,  whatever 
be  the  position  and  the  degree  of  steadiness  of  the  globe. 
And  in  most  cases  it  is  not  difficult  to  get  the  lens  or  its 
nucleus  sufficiently  delivered  to  be  seized  and  lifted  out 
by  the  fixation  forceps,  even  though  the  eye  be  directed 
somewhat  upward.  But  with  an  eyeball  swinging  rapidly 
upwards  at  intervals  there  is  danger  of  the  open  wound 
sweeping  along  an  imperfectly  sterilized  upper  palpebral 
surface.  Also  one  fears  lest  the  margin  of  the  half- 
delivered  lens  be  caught  against  the  lid  surface  and  bent 
forwards  and  downwards,  carrying  the  corneal  flap  forcibly 
down  with  it.  I  have,  however,  never  yet  seen  accident 
caused  thus.  It  may  be  necessary  to  remove  the  speculum 
for  a  couple  of  minutes  or  so,  and  to  instil  cocain  to  enable 
the  patient  to  regain  some  self-control.  Afterwards  as  little 
is  said  as  possible  to  him,  and  one  must  be  prepared  to  ex- 
press the  lens  with  the  eye  perhaps  turned  a  little  upwards. 
Fixation  with  forceps  may  help  a  little  to  restrain  upward 
movement,  and  also  may  assist  directly  in  the  expulsion 
of  the  lens. 

The  delivery  of  a  cataract  is  thus  in  the  great  majority 
of  cases  by  expulsion  or  expression.  The  comparatively 
rare  extraction  or  withdrawal  by  means  of  sharp  hook  or 
forceps,  or  spoon  or  wire  loop,  is  practised  where  opaque 
capsule  needs  removal,  or  where  expulsion  is  inapplicable 
on  account  of,  or  from  fear  of,  rupture  of  the  zonule. 

In  von  Graefe's  earlier  modified  linear  operations  the  exit  of 
the  lens  through  the  narrow  wound  had  to  be  assisted   by 

9 


13°  Cataract  Extraction 

traction  with  sharp  hook  in  about  two-thirds  of  the  cases — i.e., 
whenever  there  was  a  hard  nucleus  of  some  size. 

It  is  more  particularly  during  this  stage  of  the  operation 
and  afterwards  that  one  may  be  troubled  by  undesirable 
evidences  either  of  excessive  or  of  deficient  tension  in  the 
eye.  On  the  one  hand  there  may  be  an  alarming  tendency 
to  expulsion  of  the  contents  of  the  globe,  or,  on  the  other 
hand,  falling  back  of  the  cornea  to  occupy  the  space 
resulting  from  the  loss  of  the  lens  and  of  aqueous  humour, 
or  more  rarely  some  collapse  of  the  globe  as  a  whole. 
The  two  conditions  seldom  bear  any  relation  to  the  tension 
of  the  eye  as  tested  clinically  before  operation.  The  eyes 
which  become  slack  during  operation  may  even  feel  harder 
than  normal  beforehand,  owing  to  senile  rigidity  of  the 
sclerotic.  And,  according  to  my  experience,  the  '  vitreous 
tension '  observable  after  the  eye  has  been  opened  may 
be  absent  in  glaucomatous  eyes.  Certainly  very  marked 
examples  of  it  are  seen  in  eyes  apparently  normal  except 
for  the  cataract  present. 

Though  well  marked  cases  of  vitreous  tension  are  de- 
cidedly uncommon,  minor  grades  of  the  tendency  are 
fairly  frequently  met  with.  The  patients  are  usually  com- 
paratively young — perhaps  forty  or  forty-five  years  old — 
and  stouter  in  physique  than  the  average.  Their  eyelids 
are  sometimes  noticeably  tense,  so  that  one  cannot  raise 
them  well  from  the  globe  by  the  speculum,  and  the  eye- 
balls are  often  somewhat  prominent.  The  anterior 
chamber  is  frequently  shallow,  and  the  lens  usually 
contains  soft,  flocculent,  cortex.  But  the  indications  are 
neither  sufficiently  constant  nor  sufficiently  characteristic 
to  enable  one  to  recognize  the  eyes  beforehand.  How- 
ever, the  conditions  responsible  for  this  vitreous  tension 
being  bilateral,  one  is  able  after  operation  upon  one  eye  to 
anticipate  it  in  the  fellow  eye. 


Description  of  the  Operation  131 

As  the  section  nears  completion  the  lens  and  iris  are 
pressed  forward  against  the  cornea,  precluding  the  admis- 
sion of  any  blood  into  the  anterior  chamber.  As  soon  as 
the  capsule  has  been  opened,  the  lens,  or  the  greater  part 
of  it,  tends  to  slip  upward,  presenting  in  the  wound.  The 
lens  may  then  slowly  rise  and  make  its  exit  spontaneously. 
Or  a  mere  touch  with  an  instrument  on  the  lower  part  of 
the  cornea,  or  a  slight  forward  pull  on  the  conjunctival 
flap  is  sufficient  to  deliver  the  lens.  Afterwards  the  section 
may  remain  pressed  a  little  open,  and  iris  is  apt  to  be 
incarcerated  at  each  end,  and  to  resist  the  feeble  attempts 
at  replacement  which  one  may  feel  justified  in  making. 
Hence  possibly  permanent  defects — considerable  astigma- 
tism, and  all  the  possibilities  associated  with  prolapse  or 
incarceration  of  iris.  And  if  the  cataract  is  at  all  unripe, 
much  cortex  may  have  to  be  left  behind,  since  the  usual 
measures  comprised  in  the  *  toilet '  of  the  eye  are  applic- 
able to  only  a  very  limited  extent.  The  speculum  is 
maintained  most  carefully  elevated,  and  the  eye  kept  as 
quiet  as  possible,  and  the  operation  finished  quickly  for 
fear  of  rupture  of  the  suspensory  ligament.  Such  eyes  are 
supremely  unfitted  for  intracapsular  extraction  of  the  lens. 
Any  opening  in  the  posterior  capsule  or  zonule  must  lead 
to  a  considerable  loss  of  vitreous.  And  ordinary  simple 
extraction  is  obviously  inapplicable.  The  iridectomy 
should  be  larger  than  usual. 

More  or  less  evidence  of  the  opposite  condition — slack- 
ness of  the  eye — is  more  common.  It  is  seen  more 
particularly  in  the  older  patients.  A  considerable  propor- 
tion of  them  are  emaciated,  with  sunken  eyeballs  and  lax 
lids.  Blood  and  irrigating  fluid  tend  to  accumulate  in  the 
anterior  chamber  until  expelled  by  external  pressiure. 
There  may  or  may  not  be  marked  rigidity  of  the  sclerotic. 
In  the  former  case  the  cornea  falls  back  into  a  deep  cup 

9—2 


132  Cataract  Extraction 

as  soon  as  the  body  of  the  lens  has  been  expressed,  and  this 
persists  after  removal  of  the  speculum.  In  the  latter  case 
the  cupping  is  less  deep,  and  there  may  be  some  infolding 
of  the  inelastic  sclerotic.  These  conditions  may  perhaps 
be  seen  only  while  the  speculum  is  elevated.  Should  the 
latter  be  released,  the  weight  of  the  instrument  and  of  the 
lids  may  restore  the  globular  shape  of  the  eye.  Where 
the  sclerotic  is  quite  rigid,  the  removal  of  cortical  remains 
by  external  pressure  is  impossible  unless  the  scleral  lip  of 
the  wound  is  well  depressed.  The  lens  matter  may,  how- 
ever, be  washed  out  and  the  cornea  refloated  by  a  stream 
of  fluid  from  the  irrigator.  These  slack  eyes  are  well 
suited  for  intracapsular  extraction,  because  there  is  no 
tendency  to  loss  of  vitreous  except  by  external  pressure. 
They  are  also  well  suited  for  simple  extraction,  since 
prolapse  of  iris  is  unlikely  to  occur. 

I  have  only  seen  one  case  of  the  rare  extreme  collapse 
of  the  globe,  of  which  isolated  reports  have  been  published. 

The  lens  was  overripe,  consisting  of  nucleus  and  capsule 
only,  not  tremulous.  As  it  did  not  come  easily,  the  zonule 
was  purposely  torn  by  pulling  on  the  lens  with  a  blunt  cysti- 
tome.  The  collapse  of  the  eye  came  on  gradually,  but  there 
was  no  evidence  of  escape  of  vitreous.  The  lens  had  to  be 
delivered  by  loop  within  the  eye  and  pressure  outside.  Finally, 
the  sclerotic  was  much  folded  and  the  corneal  lip  of  the  wound 
overlapped  the  scleral  lip  considerably. 

The  explanation  of  these  conditions  is  largely  conjectural. 
Variations  from  the  normal  elasticity  and  firmness  of  the 
sclerotic,  and  in  the  position  of  the  globe  as  affected  by 
increase  or  absorption  of  orbital  fat,  influencing  the  tension 
of  the  recti  muscles,  are  obvious  explanatory  suggestions. 
Possible  spasm  of  the  tensor  choroidese,  suggested  by 
Nicati  as  a  cause  of  spontaneous  expulsion  of  vitreous, 
may  be  mentioned  in    connexion  with   vitreous  tension. 


Description  of  the  Operation  133 

Corneal  collapse  is  said  to  be  predisposed  to  by  over-free 
instillation  of  cocain.  The  gradual  onset  of  the  state  of 
collapse  of  the  globe  in  the  case  just  related  appeared  to 
show  drainage  from  an  extraordinarily  fluid  vitreous.  The 
condition  predicates  an  atrophy  of  the  vitreous,  and 
possibly  also  an  atrophic  zonule  (Czermak).  Chodin,* 
who  published  two  cases,  thought  the  sclerotic  might  have 
been  of  extraordinary  tenuity,  and  without  elasticity. 

All  operators  of  any  considerable  experience  must  at 
times  have  been  relieved  of  the  necessity  of  delivering  the 
lens,  by  its  accomplishment  through  spasm  of  the  orbicu- 
laris forcing  the  arms  of  the  speculum  or  the  retro-tarsal 
portions  of  the  lids  on  to  the  globe.  According  to  the 
stage  at  which  this  occurs  one  may  be  relieved  also  of  the 
necessity  of  iridectomy,  and  of  capsulotomy.  Rarely  the 
lens  alone  may  escape  unaccompanied  by  vitreous.  The 
somewhat  bulky  list  of  troubles  and  difficulties  above 
detailed  might  well  incline  one  to  the  endeavour  to  simplify 
matters  by  delivery  of  the  lens  in  its  capsule.  But  many 
of  the  troubles  described  are  only  rarely  encountered. 
And  due  recognition  of  the  difficulties  ensures  that  few  of 
them  need  prove  insurmountable,  or  even  grave. 


TOILET  OF  THE  EYE. 

The  procedures  embraced  by  this  term  are  to  be  con- 
sidered in  three  subdivisions :  I,  the  removal  of  lenti- 
cular cortex,  blood,  and  free  iris  pigment  from  within  the 
globe;  II,  the  replacement  of  iris  and  of  capsule  and 
the  adjustment  of  the  wound  surfaces,  free  from  entangle- 
ments; and  III,  the  cleansing  of  the  conjunctiva  and  of 
the  lid  borders. 

*   Westnik  Ophth.,  xi  (1894),  78. 


134  Cataract  Extraction 

I,  Such  blood-clot  as  may  have  escaped  expulsion  with 
the  lens  will  be  found  to  be  held  by  adhesions  to  lens 
capsule  or  to  iris.  Some  of  it  may  come  away  with  the 
lens  cortex,  but  often  it  has  to  be  left  to  become  absorbed, 
and  it  may  render  the  removal  of  cortex  more  difficult. 
Any  small  quantity  of  aqueous  now  accumulating  in  the 
anterior  chamber  (in  slack  eyes)  usually  appears  muddy 
from  admixture  of  traces  of  blood  and  of  iris  pigment.  It 
may  be  expressed  through  the  wound  by  the  curette  or 
lens  expressor.  Its  expulsion  serves  to  wash  out  the 
chamber  a  little,  and  may  be  facilitated  b}^  depressing  the 
scleral  lip  of  the  wound.  Any  bright  fluid  flood  present 
in  the  chamber  naturally  demands  expression  or  washing 
away.  But  should  the  chamber  refill  at  once  from  bleed- 
ing vessels  covered  by  conjunctival  flap,  repeated  expression 
is  useless,  and  the  blood  must  be  left  for  absorption.  In 
a  few  eyes  there  is  to  be  seen  a  considerable  quantity  of 
dust-like  pigment,  rubbed  off  the  back  of  the  iris  by  the 
pressure  and  friction  of  the  escaping  lens.  It  seems 
better  to  wash  out  these  minute  particles,  lest  they  should 
aid  in  the  lodgment  and  growth  of  any  micro-organisms 
which  may  gain  an  entrance. 

An  air-bubble  may  also  need  expulsion  from  the 
anterior  chamber  by  pressure  or  by  the  douche.  A  little 
air  is  liable  to  be  sucked  in  through  the  wound  at  times, 
when  the  latter  is  opened  by  the  introduction  of  instru- 
ments, especially,  perhaps,  in  eyes  with  collapsed  cornea. 
If  its  removal  proves  troublesome  it  may  be  left  to  become 
absorbed. 

But  our  chief  concern  is  with  any  cortical  matter  which 
remains  after  the  expulsion  of  the  bulk  of  the  lens.  In 
few  instances  of  ordinary  cataract  extraction  are  the 
contents  of  the  lens  capsule  expelled  absolutely  in  one 
mass.     Even  where  the  cortex  is  abnormally  firm  and  not 


Description  of  the  Operation  135 

readily  separable  from  the  nucleus,  equatorial  fragments 
are  not  infrequently  broken  off  and  left  behind.  Where 
the  cortical  layers  are  softened  and  broken  up  large 
amounts  may  be  left  behind,  so  much  so  that  occasionally 
in  a  faulty  operation  the  nucleus  slips  out  alone.  Even 
in  Morgagnian  cataracts,  in  the  occasional  examples 
when  the  fluid  is  slightly  creamy  in  consistence,  some  of 
this  most  irritating  fluid  may  need  removal  from  behind 
the  iris.  In  operating  upon  distinctly  unripe  cataracts  with 
superficial  layers  scarcely  changed  at  all  from  the  normal 
transparency,  unless  great  care  has  been  taken  to.  secure 
initial  dislodgment  from  the  lower  periphery,  very  much 
sticky  substance  may  remain.  Its  exact  limits  will  not 
be  clearly  recognizable  till  the  following  day,  when,  by 
clouding,  it  will  have  become  readily  visible,  and  by  rapid 
swelling  it  may  have  expanded  to  fill  up  the  whole  of  the 
pupillary  area  and  coloboma. 

The  Removal  of  Cortex. — Lens  remnants  may  be  dis- 
placed either — (i)  by  expression,  or  (2)  directly  with 
curette  or  spoon,  or  (3)  by  irrigation.  Should  the  first 
method — the  least  objectionable — prove  very  inadequate, 
it  may  have  to  be  supplemented  by  one  of  the  others. 

(i)  Ripe  cortex,  whether  firm  or  flocculent,  may  often 
be  removed  fairly  completely  after  the  delivery  of  the 
bulk  of  the  lens  by  external  pressure.  And  even  unripe, 
and  therefore  somewhat  sticky,  material  may  be  got  away 
fairly  well  if  it  has  already  been  a  little  displaced  from  its 
original  bed  during  the  expulsion  of  the  lens.  Those  who 
deliver  the  lens  by  digital  pressure  through  the  lower  lid 
naturally  utilize  the  same  means  to  express  the  cortical 
remains ;  and  many  who  use  instrumental  pressure  for 
the  body  of  the  lens  prefer  to  remove  the  speculum  and 
practice  the  *  lid  manoeuvre,'  for  the  remaining  cortex.  In 
the   time-honoured  '  milking '   movements,  the   finger   is 


136  Cataract  Extraction 

applied  with  light  pressure  over  the  closed  lids.  Rotatory 
and  radial  movements  over  the  cornea  collect  the  lens 
matter  from  the  periphery  towards  the  pupil.  And  the 
border  of  the  lower  lid  is  utilized  to  push  the  cortex  up 
through  the  wound,  the  upper  lid  being  drawn  up  from 
the  globe. 

The  same  objection  applies  to  this  use  of  the  lower  lid 
on  the  score  of  infective  risk,  as  in  expulsion  of  the  lens. 
Czermak  used  direct  pressure  upon  the  cornea  with  his 
forefinger  clothed  in  a  sterilized  closely  fitting  rubber 
covering. 

I  have  preferred  always  to  continue  with  the  same 
instrumental  pressure  and  movements  as  in  delivering  the 
lens.  Repeated  light,  quick  strokes  upon  the  cornea  with 
the  convexity  of  spoon  or  curette  or  hook  are  commonly 
effective  in  moving  the  underlying  cortex.  The  passage 
of  the  material  out  of  the  eye  is  facilitated  by  depression 
of  the  posterior  lip  of  the  wound.  This  is  particularly 
necessary  in  eyes  with  cupped  cornea.  In  such  eyes, 
with  the  sclerotic  pressed  well  back  by  a  curette,  there  is 
no  especial  difficulty  in  expelling  lenticular  debris,  whereas 
without  this  counter-pressure  above  nothing  is  in  the  least 
effective  but  irrigation.  Persistent  efforts  to  express 
refractory  cortex  are  inadvisable  because  the  zonule  or 
posterior  capsule  easily  gives  way,  and  because  of  the 
continued  slight  bruising  of  the  iris,  rubbing  off  its 
posterior  layer  of  pigment  cells  and  doubtless  rendering 
its  tissue  more  vulnerable  to  the  attacks  of  micro- 
organisms. 

(2)  It  is  a  fairly  common  practice  to  withdraw  a  particle 
or  two  of  lens  substance  from  the  neighbourhood  of  the 
wound  by  the  introduction  of  the  curette.  But  all  un- 
necessary insertion  of  instruments  for  this  purpose  is  to 
be  deprecated.     There  is  the  minor  risk  of  puncturing  the 


Description  of  the  Operation  137 

zonule  or  capsule,  and  the  much  graver  danger  of  carrying 
in  infection  from  the  conjunctival  surface. 

(3)  Irrigation  of  the  chambers  and  of  the  capsular  sac 
may  be  decided  upon  as  advisable  or  necessary  for  the 
final  removal  of  cortex,  blood,  or  iris  pigment.  But  it  is 
well  alvi^ays  first  to  dislodge  peripheral  fragments  by  light, 
intermittent,  jerky  pressure  with  spoon  or  hook  over  the 
corresponding  portions  of  the  corneal  circumference  and 
neighbouring  sclerotic. 

{a)  By  Siphon- Douche. — The  flask  is  held  at  an  elevation 
of  rather  less  than  a  foot  above  the  eye.  The  tube  of  the 
irrigator,  taken  from  the  attendant,  is  grasped  between 
the  finger  and  thumb  close  to  the  nozzle,  and  a  stream  of 
fluid  directed  on  to  the  globe  and  into  the  lower  fornix  to 
cleanse  these  surfaces  as  thoroughly  as  possible.  If  the 
eyeball  be  at  all  sunken,  and  still  more  if  the  palpebral 
aperture  be  shortened  from  old  trachoma,  the  lids,  elevated 
by  the  speculum,  form  a  deep  cup  in  which  the  irrigating 
fluid  collects,  covering  the  globe.  The  pool  of  fluid  may 
be  drained  away  by  tilting  the  head  well  to  the  side,  and 
by  the  assistant  allowing  the  speculum  to  fall  back  upon 
the  eye.  But  more  than  momentary  release  of  the 
speculum  is  not  permissible  except  in  the  case  of  reliable 
patients.  And  there  are  eyes  so  sunken  that,  even  with 
the  speculum  unsupported  and  the  head  moderately  tilted, 
the  wound  cannot  be  kept  above  the  level  of  the  fluid 
which  collects  in  the  conjunctival  sac  whenever  the  stream 
is  allowed  to  enter.* 

In  such  eyes  irrigation  should  be   avoided  altogether 

unless  the  healthiness  of  the  conjunctiva  is  undoubted. 

For  if  the  irrigator  nozzle  be  inserted  into  a  wound  thus 

*  This  covering  of  the  wound  by  the  fluid  accumulating  in  the 
conjunctival  sac  is  impossible  to  avoid  in  most  eyes  if  a  downward 
section  be  made.  This  constitutes  a  minor  objection  to  the  lower 
section. 


138 


Cataract  Extraction 


covered  with  fluid,  the  ingoing  stream  (unless,  possibly, 
if  the  end  of  the  nozzle  be  passed  far  within  the  chamber) 
must  suck  in  also  a  current  of  fluid  from  the  conjunctival 
sac.  The  risk  of  thus  drawing  in  micro-organisms  is 
very  obvious,  though  it  may  be  urged  that  immediately 
after  a  thorough  douching  there  can  be  extremely  few 
surface  organisms  remaining  so  loosely  attached  as  to  be 
possibly  carried  by  a  feeble  current  into  the  eye.     A  very 


Fig.  69.  —Irrigation  of  the  Anterior  Chamber. 

free  use  of  the  douche  should  be  confined  to  eyes  with 
conjunctivae  presumably  free  from  pathogenic  organisms, 
and  in  which  there  is  no  difficulty  in  keeping  the  wound 
above  the  level  of  the  conjunctival  pool  of  fluid. 

The  tip  of  the  nozzle  being  then  brought  quite  close  to 
the  wound,  a  little  above  it,  the  stream  from  it  may  often 
be  thrown  into  the  chamber,  especially  if  the  conjunctival 
flap  be  lying  turned  down  over  the  cornea.  This  may 
suffice  to  float  up  through  the  incision  some  or  all  of  the 
cortex  still  remaining  in  the  e)'e.     But  usually  the  extreme. 


Description  of  the  Operation  139 

end  of  the  nozzle  has  to  be  inserted  at  one  angle  of  the 
wound  (see  Fig.  69),  its  direction  being  transverse  or 
oblique,  and  fixation  of  the  globe  being  commonly  dis- 
pensed with.  And  the  stream  is  directed  on  to  any 
particles  of  lens  matter  within  range.  The  same  may 
need  to  be  repeated,  possibly,  at  the  other  end  of  the 
section.  Refractory  peripheral  fragments  may  perhaps 
be  made  to  move  by  allowing  the  current  to  play  all 
round  them.  Should  the  douche  prove  ineffective,  it  is 
stopped  temporarily  while  light,  jerky  external  pressure  is 
again  applied  at  the  corneal  margin,  especially  in  the 
position  corresponding  with  the  refractory  piece  of  cortex. 
Once  the  movement  inwards  from  the  periphery  has  been 
thus  begun,  the  douche  readily  obtains  a  purchase  upon 
the  dislodged  particle. 

In  perfectly  steady  eyes  the  tip  of  the  nozzle  may  be 
passed  far  into  the  globe,  behind  the  iris  if  necessary, 
even  below.  Bringing  the  mouth  of  the  tube  thus  quite 
close  to  a  piece  of  cortex  undoubtedly  enhances  consider- 
ably the  effect  of  the  stream  upon  it.  And  the  force  of 
the  current  may  be  momentarily  increased  by  the  atten- 
dant raising  the  flask  to  a  height  of  rather  more  than  a 
foot  above  the  eye.  But  it  is  rarely  necessary  to  point 
the  nozzle  directly  downwards  within  the  chamber. 
When  this  is  done,  it  is  well  for  the  assistant  to  bring  the 
fixation  forceps  into  use  again,  to  restrain  any  possible 
upward  movement  of  the  globe  likely  to  thrust  the 
cannula  through  the  posterior  capsule.  It  is,  on  the 
whole,  preferable  to  leave  a  little  lens  matter  in  the  eye 
rather  than  to  introduce  the  nozzle  repeatedly  far  within 
the  chamber,  and  rather  than  to  irrigate  very  freely. 

A  fragment  of  lens  substance  may  defy  efforts  at 
removal  through  having  become  attached  to  the  iris  by  a 
thread  of  blood-clot,  though  otherwise  free  and  movable. 


140  Cataract  Extraction 

Another  temporary  annoyance  is  that  particles  are 
occasionally  whirled  repeatedly  around  in  the  chamber 
instead  of  coming  up  through  the  wound.  The  nozzle 
may  sometimes  be  of  service,  with  the  stream  stopped  for 
the  moment,  to  sweep  up  particles  of  firm  cortex  lying 
fairly  near  the  wound,  whether  adherent  to  blood-clot  or 
not.  Small  bits  are  occasionally  driven  down  between 
the  iris  and  cornea  into  the  lower  periphery.  They  may 
even  have  to  be  left  there,  more  or  less  adherent  to  the 
iris. 

The  '  milk '  of  ordinary  Morgagnian  cataracts  is  easily 
washed  away.  Elliot,  of  Madras,  also  washes  the  nucleus 
out  from  the  eye.  But  at  times  the  fluid  part  of  the 
cataractous  lens  is  of  somewhat  creamy  consistence. 
And  (especially  in  simple  extraction)  there  may  be  some 
little  trouble  in  evacuating  the  posterior  chamber  com- 
pletely, without  passing  the  nozzle  of  the  irrigator  behind 
the  iris.  Alternations  of  douching  with  external  pressure 
over  different  portions  of  the  corneal  margin  is  indicated. 
We  had  two  cases  of  inflammatory  glaucoma  set  up  by 
some  of  this  irritating  material  left  behind  the  iris. 

I  have  always  expelled  any  trace  of  fluid  remaining  in 
the  anterior  chamber  after  irrigation  by  passing  the 
curette  or  tortoiseshell  spoon  upwards  over  the  cornea. 
Prolonged  contact  of  the  ocular  tissues  with  a  fluid  differ- 
ing in  composition  from  normal  aqueous,  and  perhaps  at 
a  somewhat  low  temperature,  appears  undesirable.  And 
there  are  always  doubts  as  to  the  possible  presence  of 
conjunctival  micro-organisms  in  the  fluid. 

(b)  Of  irrigation  with  a  double-current  syringe  I  have  no 
experience.  Surgeons  who  use  this  instrument  claim  that 
they  avoid  certain  dangers  and  inconveniences  associated 
with  single-current  douches.  They  hold  that  a  forcible 
current  from  the  latter  is  dangerous  and   productive  of 


Description  of  the  Operation  141 

pain  lasting  for  some  little  time  after  operation  ;  and  that 
the  stream  playing  in  the  anterior  chamber  may  hold  back 
lens  matter  in  the  posterior  chamber,  and  that  when  it  is 
directed  into  the  latter  chamber  it  tends  to  propel  the  iris 
into  the  wound  (in  simple  extraction).  But  these  objec- 
tions have  very  little  weight.  On  the  other  hand,  the 
general  need  for  the  insertion  of  the  cannula  of  the  double- 
action  syringe  far  within  the  wound  is  a  distinct  drawback, 
and  must  lead  to  occasional  accidents.  The  double 
syringe  would  appear  to  be  much  less  likely  than  the 
ordinary  douche  to  draw  conjunctival  organisms  in  through 
the  wound.  But  to  counterbalance  this  advantage,  the 
narrow  outflow  cannula  must  prove  quite  an  inadequate 
exit  for  many  of  the  fragments  of  cortex  which  are  com- 
monly washed  out  of  the  eye,  and  must  at  times  get 
choked. 

II.  The  pillars  of  the  coloboma  are  now  pushed  together 
by  the  curette*  or  iris  repositor  passed  in  horizontally  at 
each  angle  of  the  wound.  The  coloboma,  after  the  passage 
of  the  lens  and  cortical  remnants,  is  rarely  as  narrow  as  it 
might  be,  and  its  inert  pillars  are  often  slightly  folded. 
But  it  is  very  uncommon  for  any  part  of  the  iris  to  have 
been  forced  into  the  angles  of  the  wound  unless  by  vitreous 
(in  vitreous  tension  or  prolapse  or  escape).  In  this  last 
instance  comparatively  little  can  be  effected  in  the  way  of 
iris  replacement.  If  vitreous  is  not  actually  escaping, 
further  excision  of  iris  may  be  possible  at  each  side  to  free 
the  wound.  Nothing  can  be  attempted  in  any  case 
where  the  patient  has  quite  lost  control  over  his  eye 
movements,    and   cannot   keep    the   globe   steady.     The 

*  Now  often  taken  up  for  the  first  time,  and  therefore,  after  the 
rather  long  exposure  upon  the  instrument  rack,  rinsed  before  use  with 
salt  solution  from  the  irrigator. 


142  Cataract  Extraction 

horizontal  direction  of  the  instrument  is  important,*  and 
all  tendency  to  elaboration  in  procedure  inadvisable.  A 
mere  touch  or  two  with  the  point  of  the  spatula  or  curette 
upon  the  iris  at  either  side  usually  suffices  to  obliterate  its 
folds,  and  to  narrow  the  coloboma  sufficiently.  If  there  is 
at  all  a  complete  conjunctival  flap  some  lateral  movement 
of  the  intrument  may  be  required  for  its  insertion  under 
the  flap.  For  horizontal  insertion  at  the  nasal  end  of  the 
wound  the  spatula  or  curette  should  be  more  or  less 
curved.  Even  so  some  outward  rotation  of  the  globe  is 
usually  necessary,  the  patient  being  made  to  follow  with 
his  eyes  the  necessary  movement  of  his  hand,  directed  by 
the  assistant. 

We  have  found  that  with  the  narrow  iridectomy  which 
we  have  always  made,  this  replacement  of  the  iris  is  quite 
effective  also  in  reducing  possible  entanglements  of  capsule 
from  the  wound.  We  have  not  found  any  special  atten- 
tion to  the  capsule  necessary  if  the  pillars  of  the  coloboma 
be  approximated  as  well  as  they  can  be.  Some  operators, 
especially  in  simple  extraction,  prefer  to  replace  iris  and 
capsule,  particularly  when  prolapsed,  with  the  stream  from 
the  irrigator.  Should  these  means  fail,  it  is  recommended 
to  seize  the  pillars  of  the  coloboma  with  iris  forceps,  and 
to  draw  them  into  position  thus.  Should  the  iris  still  not 
remain  in  place,  the  wound  may  be  searched  diligently 
with  iris  forceps,  with  the  aid  of  focal-illumination,  for 
points  of  capsule  possibly  lying  in  it.  According  to 
L.  Miillert  a  tag  of  capsule  may  be  fixed  in  an  angle  of 

*  The  eye  is  thus  safeguarded  against  accident,  in  case  of  sudden 
upward  movement.  The  minute  and  accurate  replacement  of  the 
displaced  iris  with  a  spatula  directed  vertically  downwards  within  the 
chamber,  as  sometimes  taught,  is  a  measure  adopted  only  for  more 
reliable  and  steady  patients  than  it  has  been  my  lot  frequently  to 
encounter. 

t  KL  Mbl.f.  A.,  xl  (1902),  Bd.  i. 


Description  of  the  Operation  143 

the  wound,  and  may  hold  the  iris  fast  there  also.  The 
spatula,  in  attempts  to  replace  the  iris,  glides  over  the 
capsule  instead  of  entering  the  fold  of  the  iris. 

Knapp,  Forster,  and  Swanzy*  have  recommended  the 
routine  search  for  capsule  lying  between  the  lips  of  the 
wound.  Iris  forceps  are  passed  into  the  incision  and 
repeatedly  opened  and  closed  throughout  its  length.  Any 
portion  of  capsule  seized  is  slowly  drawn  out,  to  be  either 
snipped  off  with  scissors  or  torn  away,  with  the  assistance 
of  a  second  pair  of  forceps  if  necessary.  Swanzy  found 
capsule  in  the  wound  thus  in  about  25  per  cent,  of  his 
cases.  Loss  of  vitreous  need  not  be  feared  in  the  partial 
removal  of  capsule  if  the  speculum  be  first  removed. 
But  it  has  been  objected  that  in  drawing  out  one  portion  of 
membrane  one  may  pull  another  portion  into  the  incision. 

Should  impacted  capsule  be  keeping  the  iris  also  dis- 
placed, the  release  or  removal  of  the  entangled  shred  of 
capsule  should  enable  the  iris  to  be  fully  unfolded. 
Further  excision  of  iris  at  this  stage  of  the  operation  is  to 
be  avoided  if  possible.  It  is  often  difficult  and  dangerous 
(Chapter  IV),  and  leaves  a  broad  coloboma,  unsightly, 
and  with  visual  drawbacks.  But  it  is  vastly  preferable 
to  leaving  iris  to  heal  in  the  wound. 

The  old  operators  first  attempted  to  reduce  prolapsed 
or  incarcerated  iris  by  gentle  massage  of  the  cornea 
through  the  upper  lid.  Contraction  of  the  sphincter  may 
sometimes  be  excited  by  the  friction. 

Blood-clot  lying  about  the  wound  adherent  to  sclerotic 
and  episcleral  tissue  is  removed  with  iris  forceps  or  curette, 
or  wiped  away  with  a  sterile  moist  swab. 

The  conjunctival  flap  is  then  carefully  smoothed  out  by 
upward  strokes  over  it  with  the  point  of  the  curette.  Or, 
if  the  flap  be  very  short,  the  point  of  the  cystitome  may 

*  '  Handbook  of  Diseases  of  the  Eye,'  6th  Edition,  p.  373. 


144  Cataract  Extraction 

be  better  used  for  this  stretching-out  process,  this  in- 
strument obtaining  more  purchase  upon  the  membrane. 
The  margins  of  the  deep  wound  are  thus  closely  approxi- 
mated, except  where  the  cornea  is  collapsed,  preventing 
immediate  close  coaptation  of  the  wound  surfaces.  In 
these  cases  adjustment  of  the  wound  surfaces  may  be 
expected  to  take  place  automatically  when  the  chamber 
refills. 

The  speculum  is  now  removed.  The  assistant  gives  up 
his  hold  of  the  instrument  to  the  surgeon,  who  keeps  it 
elevated  with  one  hand,  while  he  loosens  the  screw  and 
presses  the  arms  together  with  his  other  hand.  The 
assistant  then  draws  the  lower  lid  away  from  the  speculum 
and  keeps  it  depressed  until  the  upper  arm  is  slipped  from 
under  the  upper  lid.  Should  Desmarres'  retractor  have 
replaced  the  stop  speculum,  the  lower  lid  must  be  kept 
depressed  until  the  retractor  is  removed. 

III.  In  Bombay  for  many  years  it  has  been  our  almost 
invariable  custom  now,  at  the  close  of  the  operation,  to 
pass  the  curette  lightly  over  the  whole  palpebral  con- 
junctival surface — i.e.,  over  the  whole  secretory  portion 
of  the  mucous  membrane — to  remove  mucus  a  second 
time.  Sufficient  time  has  elapsed  since  the  cleansing 
immediately  before  operation  for  a  further  secretion  of 
mucus  to  have  occurred  commonly  in  response  to  the 
perchloride  stimulus.  The  curette  used  in  this  way  often 
causes  rather  a  sore  feeling,  and  care  must  be  taken  not 
to  occasion  contraction  of  the  orbicularis.  I  have  never 
known  any  accident  from  this  cleansing  of  the  conjunctiva. 
To  guard  against  it  the  lower  lid  has  always  been  firmly 
depressed  by  the  forefinger  of  the  assistant,  the  finger 
lying  flat  upon  the  patient's  cheek,  to  be  out  of  the  way 
of  the  curette.     The  lower  lid  in  particular  needs  to  be 


Description  of  the  Operation 


145 


controlled,  because  its  pressure  upon  the  eyeball  would 
tend  to  lever  the  wound  open,  whereas  spasm  of  the 
upper  lid  would  tend  rather  to  close  the  wound.  Any 
mucus  detached  from  the  lower  fornix  and  lower  tarsal 
conjunctiva  is  washed  away  by  a  stream  from  the  irri- 
gator. The  eyelashes  of  the  upper  lid  are  then  seized  by 
the  left  forefinger  and  thumb  to  raise  the  lid  for  the  passage 
of  the  curette  beneath  it,  the  patient  looking  downwards 


Fig.  70. — Removal  of  Mucus  with  the  Curette. 

(Fig.  70).  The  curve  of  the  curette  is  forwards,  so  that 
the  point  of  the  instrument  cannot  enter  the  wound  by 
any  mischance.  Two  or  three  sweeps  of  the  instrument 
in  light  contact  with  the  stretched  palpebral  surface  are 
sufficient  to  transfer  most  or  all  of  the  secretion  to  swabs 
held  by  the  assistant. 

This  measure  is  a  continuation  of  the  cleansing  practised 
immediately  before  operation,  and  is  a  supplement  to  the 
treatment  with  strong  perchloride.  There  can  be  no  doubt  (see 
Chapter  IV)  that  the  mucus  secreted  thus  early  in  our  cases 
must  have  often  contained  pathogenic  conjunctival  organisms. 

10 


146  Cataract  Extraction 

It  seems  reasonable,  therefore,  to  remove  it  as  fully  as  possible. 
Yet  this  removal,  so  far  as  I  know,  is  exclusively  a  Bombay 
practice.  Others  who  have  used  perchloride  freely  have  not 
troubled  about  any  supplementary  cleansing,  and  have  had  • 
good  results.  We  cannot  feel  sure,  therefore,  whether  this 
measure  has  in  any  degree  served  in  its  object  of  aiding  to 
prevent  infection  of  the  wound.  Possibly  it  has  been  mainly 
or  entirely  superfluous  ;  yet  it  has  been  at  least  harmless.  And 
since  our  figures  in  regard  to  infection  have  been  quite  excep- 
tionally good,  it  may  be  that  this  simple  precaution  has 
contributed  its  mite  towards  the  complete  result.  Though 
ordinarily  microbes  imprisoned  in  mucus  may  be  unable  to 
gain  access  to  the  wound,  it  may  be  quite  otherwise  when  the 
lips  of  a  purely  corneal  wound,  uncovered  by  conjunctival 
flap,  are  not  in  good  apposition. 

Finally,  sterile  atropin  drops  may  be  instilled  if  much 
cortex  or  blood-clot  has  been  left  in  the  eye,  or  if  the  iris 
has  been  exceptionally  mutilated,  having  perhaps  shed  a 
good  deal  of  pigment ;  or  if  iritis  is  feared  from  the  con- 
dition of  the  patient,  as  in  advanced  Bright's  disease  ;  or, 
finally,  if  there  is  any  question  of  the  possibility  of 
infective  organisms  having  been  carried  into  the  wound 
— e.g.,  from  the  lid  margins.  Dilatation  of  the  pupil 
may  be  secured  now  in  cases  where  it  will  be  unob- 
tainable after  twenty-four  hours.  Since  any  tendency 
to  prolapse  of  iris  is  enhanced  by  the  atropin,  one  would 
hesitate  to  use  the  drops  in  eyes  with  vitreous  tension  or 
when  the  edges  of  the  wound  were  not  in  good  ap- 
position. 

THE  DRESSING. 

The  eyelids  are  closed  gently  by  the  surgeon.  If  the 
patient  be  told  to  close  his  eyes  he  is  apt  to  do  it  much 
too  vigorously.  A  pad  of  dry  absorbent  wool,  either  boric  or 
simple  sterilized  wool,  is  applied  on  a  few  layers  of  gauze 
and  fixed  by  a  bandage.     A  shield  is  fixed  over  all. 


Description  of  the  Operation  147 

Sterilized  iodoform  is  applied  about  the  inner  canthus  by 
some  surgeons  in  cases  where  there  has  been  lacrymal  trouble. 
At  one  time  in  Bombay  we  applied  it  regularly  over  the 
cataract  wound.  It  was  doubtful  whether  it  did  much  good, 
and  very  occasionally  a  little  of  it  found  its  way  into  the 
anterior  chamber. 

Pagenstecher  applies  von  Hoffmann's  ichthyol  dressing  over 
the  closed  lids.  Pure  ichthyol  is  smeared  over  the  lids  and 
covered  with  gauze  soaked  in  liquid  paraffin.  Absorbent  wool 
is  laid  over  this  and  kept  in  place  by  a  wire  shield  in  the  form 
of  spectacle  frames.  The  ichthyol  probably  has  some  anti- 
septic action.  Others  have  similarly  employed  boric  and  other 
ointments  to  prevent  the  drying  of  discharge  upon  the  eye- 
lashes, and  to  ofTer  a  mechafiical  obstacle  to  the  entry  of 
micro-organisms  into  the  conjunctival  sac. 

The  object  of  the  ordinary  dressing  is  to  maintain  the  lids 
at  rest  and  to  protect  the  eye  from  light  (and  from  dust  ?),  and 
to  absorb  watery  fluid  passing  out  from  between  the  lids.  It 
must  exert  little  or  no  pressure  upon  the  globe,  and  yet  must 
not  be  liable  to  accidental  displacement  or  easy  of  displace- 
ment by  the  patient.  Haab  says'''  of  a  too  tightly  applied 
dressing  :  "  The  pressure  of  such  a  dressing  constantly  re- 
opens the  wound,  and  the  patient  is  very  apt  to  try  to  over- 
come the  unpleasant  sense  of  pressure  by  closing  the  lid 
tightly,  and  thus  makes  matters  worse.  If  the  bandage  is 
too  tight,  the  tears  are  prevented  from  reaching  the  palpebral 
fissure,  because  the  lids  are  pressed  tightly  together,  and 
in  this  case,  also,  the  patient  adds  injury  by  closing  his  eyes 
still  more  firmly.  The  tears  collect  under  the  lids,  blepharo- 
spasm increases  more  and  more,  and  finally  there  is  severe 
pain,  and,  of  course,  injurious  pressure  upon  the  wound,  and 
harmful  retention  of  the  secretions,  both  from  the  wound 
and  from  the  conjunctiva."  A  displaced  dressing  not  only 
fails  in  its  object,  but  is  likely  to  press  unevenly  upon  the 
eye. 

Though  occlusion  of  both  eyes  is  required  for  some  days 
after  vitreous  accident,  and  for  one  day  after  simple  extraction, 
it  is  not  so  much  needed  after  the  combined  operation.  In 
Bombay  the  other  eye  was  simply  covered  by  a  loose  strip  of 

*  '  Operative  Ophthalmology,'  p.  48. 

10 — 2 


148  Cataract  Extraction 

lint   hanging   from   the  brow,*    where   it    was   fixed    by    the 
bandage. 

To  guard  against  the  application  of  possibly  injurious 
pressure,  the  absorbent  wool  covering  should  be  large  enough 
to  lie  over  all  the  bony  prominences  around  the  eye,  and 
should  be  of  the  same  thickness  over  them  as  over  the  lids ;  and 
the  bandage  must  be  broad.  Many  surgeons  are  careful  to  fill 
up  the  hollows  around  the  eye  to  immobilize  the  lids.  An 
ordinary  surgical  roller  bandage,  properly  applied,  affords 
reliable  fixation.  Firm  fixation  of  a  single  '  occlusive  dressing,' 
as  distinguished  from  a  '  pressure  dressing,'  is  obtainable  only 
by  turns  of  the  roller  tightly  drawn  around  the  head  and  fore- 
head, and  not  covering  the  eye.  Two  such  turns  are  sufficient, 
passing  above  the  ears,  but  rather  low  down  behind  the  head. 
And  if  the  bandage  be  broad,  2|  inches,  only  a  single  turn 
below  the  ear  and  over  the  eye  is  needed.  This  is  not  pulled 
tightly  over  the  eye,  but  is  drawn  well  up  under  the  ear.  And 
it  is  tested  by  inserting  a  finger  under  it  to  see  that  it  does  not 
lie  loosely  over  the  cheek.  This  single  turn  does  not  suffice, 
however,  to  prevent  the  patient  from  getting  his  finger  under 
the  dressing,  as  he  is  apt  to  do  when  awaking  from  sleep,  if 
there  be  any  itching  of  the  lids  from  drying  secretion.  This  is 
to  be  prevented  by  the  shield.  A  2-inch  bandage  lies  more 
smoothly  than .  a  broader  one,  becoming  less  folded  where  it 
presses  above  and  below  the  ear,  but  it  does  not  distribute  the 
pressure  so  well  over  the  margins  of  the  orbit. 

The  patient's  head  must  lie  passive,  well  supported  by  the 
assistant,  during  the  application  of  the  bandage. 

The  double  bandage  covering  both  eyes  in  a  figure-of-8  is 
more  easy  to  apply  firmly  without  pressing  upon  the  eye.  For 
the  turn  below  the  occiput  and  below  both  ears  cannot  slip, 
and,  with  both  eyes  to  be  covered,  the  turns  may  pass  less 
obliquely  across  the  face,  being  drawn  well  in  to  the  ears,  above 
and  below. 

Except  in  very  hot  weather,  the  heat  of  the  dressing  is  not 
irksome.  In  place  of  the  roller  bandage  single  strips  of 
material — gauze,  or  knitted  or  webbed  material,  more  or  less 
elastic — are  frequently  employed.  The  ends  are  fixed  by 
adhesive  plaster  or  by  tapes  above  and  below  the  ears. 

*  Owing  to  the  poor  nursing  arrangements,  the  patients  used  to 
find  their  way  about  the  wards  unassisted  almost  from  the  beginning. 


Description  of  the  Operation  149 

Russell  Murdoch's  bandage,  made  of  flannel,  is  one  which 
we  have  used  in  Bombay  with  satisfaction. 

Or  simple  strapping  may  be  employed  in  narrow  strips  from 
the  forehead  down  over  the  cheek.  The  use  of  long  strips  of 
strapping  is  unpleasant,  especially  if  the  eye  has  to  be  exposed 
more  than  once  a  day  for  the  instillation  of  atropin ;  and  short 
strips  are  liable  to  displacement. 

A  shield  is  required  to  protect  the  eye  from  injury  by 
accidental  pressure  or  by  insertion  of  the  patient's  finger  under 
the  dressing.  Among  single  models  may  be  mentioned  Fuchs' 
wire  lattice-work  screen,  also  the  perforated  aluminium  and 
Lloyd  Owen's  cardboard  '  Cartella  '  shells.  Unless  well  fixed 
by  strapping  they  are  scarcely  so  firm  as  the  double  shields. 


Russell  Murdoch's  Bandage. 


Among  the  latter  may  be  mentioned  Fuchs'  double  model  and 
Bronner's  wire  shade  (see  Instrument  Catalogues)  as  suitable 
for  application  over  the  dressing  and  for  use  after  the  dressing 
has  been  discarded. 

Haab  has  used  starched  bandages. 

AFTER-COURSE  AND  AFTER-TREATMENT. 

The  patient  is  carried  to  bed  if  the  operation  has  been 
performed  on  a  table.     He  must  expect  a  little  soreness  o 
the  eye  for  a  few  hours. 

It  is  a  usual  custom  to  keep  at  least  the  one  eye 
bandaged  for  four  days  or  so  in  uncomplicated  cases ; 
occasionally  longer,  whenever  the  healing  of  the  wound 
is  delayed.  But  every  day  the  coverings  should  be 
removed  for  inspection  of  the  eye  and  for  cleansing  of  the 
lids. 

In  our  work  the  dressing  was  frequently  found  somewhat 
discoloured  and  stiffened  after  twenty-four  hours,  and  perhaps 


150  Cataract  Extraction 

in  part  adherent  to  the  skin  of  the  lids  or  surrounding  parts, 
having  evidently  been  soaked  more  or  less  with  watery  fluid 
from  the  eye.  There  was  some  lid  swelling  from  the  per- 
chloride  treatment  of  the  conjunctiva,  which  lasted  for  a  few  days 
at  least.  For  the  first  few  days  the  eyelashes  and  lid  borders 
generally  needed  to  be  cleansed  from  mucus  accumulated 
upon  them,  with  bits  of  lint  soaked  in  i  in  5,000  perchloride. 
This  mucoid  discharge  was  frequently  more  scanty  and  more 
transient  than  that  from  the  fellow  eye,  in  which,  perhaps,  a 
chronic  conjunctivitis  had  been  aggravated  by  mere  closure  of 
the  eye,  without  bandaging.  It  was  not,  therefore,  attributable 
to  the  perchloride  irrigation.  At  these  daily  cleansings  the 
conjunctival  sac  was  not  washed  out  at  all.  Possibly  a  little 
of  the  lotion  employed  frequently  found  its  way  in  between  the 
lids,  for  we  thought  that  when  boric  lotion  was  used  for  the 
washing,  there  were  more  cases  of  troublesome  persistent  con- 
junctivitis than  when  the  i  in  5,000  perchloride  was  employed. 
The  cleansing  must  be  done  with  care,  and  possible  ill  effects 
from  spasm  of  the  orbicularis  avoided  by  keeping  the  lower  lid 
pulled  well  away  from  the  eyeball  throughout.  Pressure  of 
the  upper  lid  alone  can  do  little  harm,  as  it  keeps  the  wound 
closed,  but  pressure  of  the  lower  lid  alone  would  force  the 
wound  open. 

In  our  cases  there  was  generally  at  first  some  bulbar  con- 
junctival injection  as  well  as  considerable  ciliary  injection. 
The  former  and  much  of  the  latter  were  attributed  to  the 
strong  sublimate  solution  which  had  been  employed.  With  us 
the  ciliary  congestion  lasted  about  double  the  ordinary  period, 
which  is  said  to  average  eight  to  ten  days  for  the  redness  at  the 
sides  and  below  the  cornea,  and  fourteen  days  or  more  for  the 
congestion  localized  about  the  wound.  In  some  of  our  cases, 
however,  there  was  practically  no  redness  of  the  eye  from 
beginning  to  end. 

The  patient  is  kept  recumbent  for  twenty-four  hours.  He  is 
directed  not  to  lie  on  the  operated  side,  and  not  to  lie  con- 
tinuously upon  his  back,  lest  flatulent  distension  of  the  abdomen 
be  set  up.  He  may  turn  from  his  back  to  his  side,  and  back 
again  without  help,  but  he  should  understand  that  frequent 
turning  tends  to  loosen  the  bandage.  He  must  be  assisted  in 
rising  from  the  bed  and  in  lying  down  for  a  few  days.  Very 
old  people  and  chronic  bronchitics  may  maintain  the  sitting  or 


Description  of  the  Operation  151 

semi-recumbent  attitude  from  the  beginning,  if  they  are  suitably 
propped  up  with  pillows ;  or  they  may  change  their  position 
repeatedly,  provided  they  remain  passive  in  the  hands  of  the 
attendants  who  move  them.  A  sleeping-draught  must  be 
given,  if  found  necessary,  for  the  first  night.  The  patient  may 
sit  up  in  bed  after  twenty-four  hours,  but  even  after  the 
combined  operation  it  is  perhaps  well  that  he  should  not  leave 
his  bed  for  two  or  three  days. 

The  bowels  are  not  moved  as  a  rule  on  the  first  day,  having 
been  sufficiently  relieved  by  the  laxative  administered  before 
operation.  The  patient  must  avoid  straining  at  stool.  Sonie 
people  cannot  pass  urine  into  a  receptacle  while  in  the  recum- 
bent posture,  and  may  have  to  be  allowed  out  of  bed  for  this 
purpose.  Men  with  enlarged  prostates  are  perhaps  more 
liable  to  retention  of  urine  if  atropin  is  being  instilled  frequently 
after  operation,  and  must  be  watched  in  this  respect. 

The  patient  must  talk  little,  and  must  only  take  soft  and 
fluid  food,  requiring  no  mastication,  as  long  as  the  bandage  is 
in  use.  Any  tendency  to  coughing  is  restrained  with  morphia, 
etc. 

The  light  in  the  room  is  kept  rather  dim.  This  is  preferred 
to  ordinary  daylight  by  the  patients,  and  is  only  reasonable 
where  so  many  pass  through  at  least  the  earlier  stages  of  iritis, 
while  the  depressing  mental  influence  of  a  very  dark  room  is 
avoided. 

Healing  of  the  Wotmd. — Some  of  the  results  of  histological 
research  into  the  repair  of  corneal  and  sclero-corneal  wounds 
in  men  and  in  animals  need  brief  mention. 

The  usual  section  at  the  sclero-corneal  junction,  like  purely 
corneal  perforating  wounds,  gapes  a  little  both  superficially 
and  deeply,  from  elastic  retraction  of  Bowman's  and  Des- 
cemet's  membranes.  There  is  also  a  tendency  for  the  corneal 
flap  to  become  displaced  a  little  forward  and  to  overlap  or 
override  the  scleral  lip  of  the  wound.  The  suggestions  which 
have  been  put  forward  to  explain  this  displacement  include  the 
pressure  of  the  lids,  the  action  of  the  extraocular  muscles,  the 
ocular  tension,  and  the  normal  elasticity  of  the  cornea  released 
from  tension. 

The  middle  layers  of  the  wound  surfaces,  swollen  by  imbibition 
of  fluid,  may  come  into  direct  apposition,  or  a  narrow  space  be- 
tween them  may  be  bridged  across  by  a  plug  of  fibrinous  lymph. 


152  Cataract  Extraction 

In  either  case  retention  of  aqueous  sufficient  for  the  refilling  of 
the  anterior  chamber  commonly  results  within  a  few  hours. 
The  gaps,  superficial  and  deep,  between  the  wound  surfaces 
fill  up  in  the  course  of  two  or  three  days,  or  sometimes  con- 
siderably longer,*  by  epithelial  and  endothelial  ingrowth. 
When  this  is  complete,  the  second  stage  of  repair  is  accom- 
plished. It  is  still  only  a  temporary  and  provisional  means  of 
union,  but  much  firmer  than  the  earlier  adhesion,  and  it  is  the 
only  process  of  repair  recognizable  until  after  the  usual  period 
of  the  patient's  stay  in  hospital.  Permanent  fibrous  union 
between  the  corneal  lamellae  on  the  two  sides  is  a  slow  develop- 
ment occupying  months.  However  this  may  be,  closure  of 
the  wound  is  commonly  continuous  after  the  first  few  hours. 
It  is  only  within  twenty-four  hours  that  evidence  of  reopening 
of  the  section  after  temporary  closure  is  frequently  met  with, 
in  the  form  of  prolapse  of  iris,  or  very  rarely  of  vitreous,  or 
emptying  of  the  anterior  chamber  after  it  has  been  refilled. 
Later  than  this  the  adhesion  is  apparently  only  liable  to  be 
broken  down  by  some  definite  cause,  such  as  sneezing  or 
coughing,  or  pressure  upon  the  eye. 

Clinically,  the  gaping  of  the  wound,  superficial  and  general, 
may  be  recognized,  and  the  edges  of  the  wound  may  be 
slightly  elevated  from  imbibition  of  aqueous  and  of  tears.  The 
fluid  entering  the  tissues  also  accounts  for  a  delicate  early 
diffuse  cloudiness  spreading  for  a  short  distance  from  the  wound, 
with  a  faint  dulness  of  the  surface.  The  cloudiness  is  ex- 
aggerated later  for  a  time  by  cellular  infiltration.  The  line 
of  the  wound  remains  permanently  visible  as  a  whitish  scar. 

Sclero-corneal  incisions,  though  still  mainly  corneal,  heal  up 
somewhat  differently.  Early  cohesion  may  take  place  in  the 
same  manner,  but  the  surface  epithelium  is  separated  from 
the  wound  by  subconjunctival  tissue.  And  the  second  stage  of 
repair  is  accomplished  by  downgrowth  of  this  subconjunctival 
tissue.  And  where  there  is  an  extensive  conjunctival  flap 
covering  the  greater  part  of  the  section  it  may  exercise  a  great 
influence  upon  the  progress  of  healing.  The  flap  adheres  quite 
early  to  the  underlying  tissue  by  means  of  blood-clot  and  fibrin. 
The  aqueous,  being  then  retained  by  the  elastic  conjunctival 
covering,  stretches  and  elevates  the  flap,  and  forces  the  sclero- 
corneal  surfaces  asunder.  Temporary  breaking  down  of  the 
*  Thomson  Henderson,  Oph.  Rev.,  xxvi  (1907),  127. 


Description  of  the  Operation  153 

adhesion,  re-emptying  the  chamber  for  a  few  days,  is  not  very 
infrequent.  If  the  conjunctival  flap  be  fairly  long  as  well  as 
extensive,  the  gaping  of  the  central  portion  of  the  underlying 
wound  may  be  considerable — a  millimetre  or  more  across. 
Approximation  of  the  surfaces  may  never  be  complete,  and  the 
permanent  repair  of  the  wound  must  then  depend  largely  upon 
the  episcleral  tissue  overlying  and  occupying  the  gap.  A  '  filter- 
ing cicatrix'  results,  allowing  aqueous  to  pass  through  to  the  sub- 
conjunctival tissue  in  the  neighbourhood,  where  it  keeps  up  a 
permanent  slight  cedema. 

Clinically,  the  early  distension  of  the  conjunctival  flap 
is  a  striking  feature.  Through  the  conjunctiva  the  open 
sclero-corneal  incision  is  seen.  In  some  cases  the  fluid 
escaping  under  the  conjunctiva  diffuses  widely,  causing 
swelling  of  the  bulbar  conjunctiva  at  the  sides  and  towards 
the  lower  fornix,  and  producing  some  slight  fulness  of  the 
lids.  This  filtration  cedema  may  be  seen  without  marked 
elevation  of  the  conjunctival  flap.  It  is  paler  than  in- 
flammatory swelling,  and  is  further  distinguished  by  its 
gravitation  to  the  more  dependent  situations,  and  by  the 
absence  of  other  evidences  of  inflammatory  reaction.  The 
two  forms  of  swelling  may,  however,  be  combined. 

This  noticeable  general  filtration  oedema  subsides  in  a 
few  days.  The  swelling  of  the  conjunctival  flap  commonly 
lasts  a  few  days  longer.  When  it  subsides,  the  separation 
of  the  deep  incision  may  be  considerably  lessened. 
Speaking  generally,  gaping  of  the  sclero-corneal  section 
may  be  taken  as  evidence  that  the  conjunctival  flap  is  too 
large. 

In  the  large  majority  of  cases  sufficient  approximation 
of  wound  surfaces,  with  proliferation  and  condensation  of 
subconjunctival  tissue,  has  occurred  to  raise  the  tension 
of  the  eye  to  nearly  normal  at  the  usual  time  for  the 
patient's  dismissal  from  hospital.  For  this  rise  in  tension 
complete  approximation  is  by  no  means  always  necessary. 


154 


Cataract  Extraction 


On  the  other  hand,  a  small  percentage  of  our  cases  were 
either  kept  back  on  account  of  low  tension,  or  had  to  be 
sent  away  with  the  eye  still  quite  soft.  And  these  were 
not  always  eyes  in  which  visible  gaping  of  the  deep  wound 
persisted  (see  Chapter  V). 

A  curious  feature  of  the  healing  of  the  majority  of  our 
cataract  wounds  in  natives  of  India  was  a  subconjunctival 
pigmentation  along  the  line  of  the  cicatrix.  It  was  some- 
times scarcely  noticeable,  but  in  other  instances  very 
dark  (Fig.  72).  It  was  evidently  due  to  migration  of 
uveal  pigment,  for  there  was  always  the  usual  adhesion  of 


Fig.  72. — Pigmentation  along  Scar  Line. 

the  base  of  one  or  both  pillars  of  the  coloboma  to  the 
deep  surface  of  the  cicatrix,  and  with  the  denser  colour- 
ing sometimes  rather  more  extensive  adhesion. 

It  was  less  frequent  after  simple  extraction,  owing  to 
the  more  general  freedom  of  the  base  of  the  iris  from  the 
scar.  It  occurred  without  actual  inclusion  of  iris  in  the 
scar.  The  source  of  the  pigment  was  shown  clearly,  also, 
by  its  tint.  The  minute  particles  of  which  the  whole  was 
composed  appeared  quite  black,  whereas  the  neighbouring 
conjunctival  pigment  was  brown.  The  colouration  was 
at  its  height  two  or  three  months  after  operation,  and 
gradually  subsided  in  the  course  of  several  succeeding 
months. 

We  had  the  opportunity  of  examining  many  eyes  a  few 


Description  of  the  Operation  155 

years  after  our  operations — up  to  nine  years.  Many  of 
the  operations  had  been  performed  with  unnecessarily 
large  conjunctival  flaps.  There  were,  consequently,  many 
cicatrices  certainly  filtering,  and  many  others  doubtful  in 
this  respect. 

The  chief  sign  of  filtration  was  oedema  of  the  conjunctiva, 
extending  for  some  distance  from  the  scar,  and  recognizable  by 
the  abnormal  size  and  depth  of  the  pits  produced  by  light 
touches  with  the  point  of  a  probe.  The  oedema  was  usually 
rather  more  marked  about  one  portion  of  the  scar  line  than 
elsewhere.  It  could  often  be  increased  by  finger  pressure  upon 
the  globe,  applied  for  half  a  minute  or  more  through  the  lower 
lid.  The  central  portion  of  the  cicatrix  was  visible  as  a  broad 
uniformly  grey  line  under  the  conjunctiva,  tapering  at  either 
end.  The  lower  limit  of  the  scar  was  sometimes  sharply 
defined  by  a  line  more  intensely  white  than  the  neighbouring 
sclerotic,  representing  the  margin  of  the  sclero-corneal  flap. 
There  were  no  dark  points  in  the  scar  suggestive  of  fistulae, 
and  no  bulging  or  unevenness.  The  ocular  tension  was  normal 
or  only  slightly  subnormal,  but  could  be  reduced  rapidly  by 
pressure  upon  the  eye. 

At  the  first  dressing,  twenty-four  hours  or  rather  less 
after  operation,  the  condition  of  the  interior  of  the  eye 
more  urgently  demands  investigation  than  that  of  the 
wound.  A  careful  examination  of  the  pupillary  area  and 
coloboma  and  of  the  iris  is  made  under  focal  illumination. 
The  light  of  a  candle  or  lamp,  focussed  with  a  pocket  lens, 
is  thrown  upon  the  parts  from  the  side,  so  that  no  direct 
rays  can  reach  the  fundus  and  excite  reflex  closure  of  the 
lids.  It  is  only  by  such  early  examination  that  the 
necessary  means  can  be  taken  to  break  down  early 
adhesions  between  iris  and  capsule,  to  remove  the  iris 
from  contact  with  iritating  lens  debris,  and  to  control 
iritis,  infective  and  otherwise.  At  least  in  our  work,  after 
the  use  of  strong  perchloride  lotion,  early  dilatation  of  the 


156  Cataract  Extraction 

pupil  was  considered  necessary  or  advisable  in  the  large 
majority  of  cases — that  is,  in  practically  all  cases  in  which 
the  pupil  did  not  react  to  the  light  thrown  into  the  eye. 
And  often  the  number  of  atropin  instillations  made  during 
the  first  few  days  was  limited  only  by  the  necessity  of 
avoiding  general  symptoms  (see  Chapter  V).  It  is  a  good 
plan  to  have  the  drops  warmed  to  avoid  causing  reflex 
closure  of  the  lids. 

After  the  final  removal  of  pad  and  bandage,  the  eye 
is  still  kept  protected  by  the  wire  shield  till  the  patient's 
discharge  from  hospital.  Ten  days  after  operation  the  eye 
is  examined  to  see  if  the  patient  is  fit  for  discharge,  or 
requires  a  '  needling '  for  after-cataract.  The  needling  is 
then  performed  if  required,  and  the  patient  kept  in  for 
a  day  longer.  Otherwise  if  the  case  has  progressed 
favourably  it  is  now  practically  at  an  end.  The  vision  is 
tested  with  glasses,  and  the  patient  sent  out  wearing 
simple  plane  smoked  glasses  as  long  as  any  redness  of  the 
eye  persists.  Correcting  lenses  should  not  be  used,  as  a 
rule,  for  a  couple  of  months*  after  operation  ;  this  ensures 
that  no  writing  or  reading  shall  be  attempted.  A  few  of 
our  cases  were  kept  back  if  there  were  beds  available — • 
cases  in  which  the  tension  was  still  very  low,  or  in  which 
there  was  some  suspicion  of  slight  iritis.  And  of  course 
cases  presenting  definite  complications  had  to  be  kept 
back. 

On  focal  illumination  adhesion  of  the  base  of  one  or 
both  pillars  of  the  coloboma  to  the  back  of  the  cornea 
at  the  line  of  incision  can  be  made  out  in  the  large 
majority  of  cases.  The  capsule  should  be  seen  in  a  plane 
more    posteriorly.      Quite    occasionally   more    extensive 

*  Most  of  our  hospital  patients  were  not  seen  again.  They  were 
provided  with  cheap  spectacles,  spherical  lenses,  but  told  not  to  wear 
them  till  the  two  months  had  expired. 


Description  of  the  Operation  157 

adhesion  of  the  base  of  the  iris  will  be  found,  though 
the  healing  of  the  wound  may  have  progressed  uninter- 
ruptedly. Thereby  more  or  less  shallowing  of  the  chamber 
above  is  produced,  and  tremor  of  the  iris  prevented.  The 
iris,  when  free  from  adhesion  both  to  the  line  of  the  wound 
and  to  the  capsule,  generally  hangs  so  loosely  that  it  is 
shaken  by  every  movement  of  the  eye. 

A  few  simple  directions  to  the  patient  are  advisable 
on  discharge,  that  he  may  refrain  from  stooping  and  from 
all  powerful  exertion.  And  it  is  well  to  keep  all  patients 
under  observation,  if  possible,  who  are  allowed  to  leave 
hospital  with  considerable  ciliary  injection,  or  with  some 
slight  traces  of  iritis. 

Post-Operative  Astigmatism. — In  testing  the  vision  at  the 
time  of  discharge  from  hospital  the  proportion  of  patients 
requiring  a  convex  cylindrical  lens  with  axis  horizontal  or 
nearly  so,  in  addition  to  the  usual  spherical  lens,  varies  con- 
siderably with  the  method  of  operation  practised,  and  with 
several  factors  as  yet  imperfectly  studied.  This  astigmatism 
has  been  shown  to  be  due  not  only  to  vertical  flattening  of  the 
cornea,  but  also  to  an  increase  in  the  horizontal  curvature.* 
In  some  cases  the  degree  of  astigmatism  found  a  fortnight  or 
so  after  operation  persists  unaltered,  or  even  increased  later.  In 
others  it  either  diminishes  somewhat  or  entirely  disappears  in 
the  course  of  a  few  months.  Reduction  in  the  amount  of  the 
corneal  flattening  may  safely  be  ascribed  to  gradual  adjust- 
ment of  the  wound  surfaces,  displaced  by  forward  springing 
and  overriding  of  the  corneal  flap.  In  sclero-corneal  sections 
the  downgrowth  of  episcleral  tissue  interposes  a  wedge  between 
the  wound  surfaces,  keeping  them  apart.  Hence  the  permanent 
element  in  the  abnormal  curvature  is  commonly  greater  in 
sclero-corneal  than  in  purely  corneal  incisions.  The  astigmatism 
from  a  corneal  section  is  apt  to  be  greater  the  nearer  the  sec- 
tion to  the  centre  of  the  cornea.  Jackson  f  found  that  in  only 
15  per  cent,  of  cases  was  the  permanent  amount  of  astigmatism 

*  Treutler,  Zeit.  f.  A.,  June,  1900. 
t  Op/i.  Review^  xii  (1893),  349. 


158  Cataract  Extraction 

reached  within  two  months,  while  in  20  per  cent,  regressive 
changes  continued  for  more  than  three  months. 

RoUet,*  reporting  on  150  cases,  found  that  in  from  two  to 
five  months  after  operation  25  per  cent,  of  the  corneas  were 
free  from  asymmetry,  while  the  remainder  had  a  mean  astig- 
matism of  2-57  D.  A  year  or  more  after  operation  there 
was  either  complete  disappearance  of  the  astigmatism  or  the 
development  of  a  small  degree  at  right  angles  to  the  original. 

Clark  f  (Columbus,  Ohio)  reports  an  interesting  observation 
of  a  case  in  which  increase  of  corneal  curvature  was  due  to  a 
band  of  pupillary  membrane,  maintaining  the  convexity  of  one 
meridian  of  the  cornea  like  the  string  of  a  bow.  Division  of 
the  band  reduced  the  curvature  by  1-25  D.  This  observation 
suggests  that  a  factor  in  the  production  of  the  early  overriding 
of  the  corneal  flap  may  be  the  vertical  tension  of  the  mem- 
branous diaphragm,  composed  of  lens  capsule  and  zonule, 
acting  upon  the  posterior  lip  of  the  wound.  The  axis  of  the 
correcting  lens  is  nearly  always  parallel  to  the  base  line  of  the 
section,  but  the  astigmatism  is  sometimes  irregular. 

For  some  years  I  have  taken  such  opportunities  as  have 
presented  themselves  in  private  practice  of  noting  the  degree 
and  progress  of  the  astigmatism  in  my  own  cases.  The  amount 
at  the  time  of  ordering  spectacles,  generally  about  two  months 
after  operation,  has  varied  from  nil  to  as  much  as  seven 
dioptres.  I  have  been  struck  by  the  small  amount  of  change 
which  has  taken  place  after  the  first  examination  about  a 
fortnight  after  operation.  This  has  usually  persisted  with 
little  appreciable  alteration  for  years.  The  absence  of  any 
notable  tendency  to  diminution  of  the  astigmatism  must  be 
counted  a  definite  drawback  to  the  use  of  a  large  conjunctival 
flap.  Still,  compared  with  the  question  of  the  safety  of  the 
eye,  abnormal  corneal  curvature  is  a  very  minor  considera- 
tion. Some  eyes  with  the  larger  degrees  of  astigmatism  have 
with  correction  attained  excellent  central  vision.  And  it  has 
been  remarked  that  it  is  to  the  general  advantage  of  the 
patients  to  accept  a  low  grade  of  average  vision  rather  than  to 
considerably  improve  the  average  visual  results  at  the  cost  of  a 
fractional  percentage  of  total  loss.     In  a  few  of  our  cases  the 

*  Rev.   GenSrale  ctOph.,  Juin,  1904.      Ref.    The   Ophthalmoscope, 

ii  (1904),  523- 

t  Ann.  of  Ophth..,  viii  (1899),  504. 


Description  of  the  Operation  159 

eyes  examined  months  or  years  after  the  prescribing  of  glasses 
have  shown  even  a  sHght  increase  in  the  degree  of  astigmatism. 
Our  results  show  that  progressive  contraction  of  the  sclero- 
corneal  gap  often  formed  under  a  large  conjunctival  flap  is  not 
to  be  anticipated.  Cicatrization  apparently  takes  place  solely 
by  the  consolidation  of  the  overlying  tissue  and  by  filling  up  of 
the  gap  by  downgrowth  of  this  tissue.  (Possibly  narrowing 
of  the  interspace  might  have  been  brought  about  by  a  pressure 
bandage,  begun  a  week  or  so  after  operation.) 

The  visiial  result  attained  at  the  time  of  discharge  from 
hospital  is  often  comparatively  poor  in  spite  of  a  clear  pupil 
(perhaps  cleared  by  needling),  and  of  correction  of  astigmatism, 
and  there  is  steady  improvement  in  the  course  of  a  few  months. 
Some  of  the  early  defects  may  at  times  be  ascribed  to  the  fine 
lines  on  the  posterior  surface  of  the  cornea  described  in 
Chapter  V.  Where  the  cataract  has  existed  for  a  long  time,  as 
is  often  the  case  in  India,  there  may  be  amblyopia  from  disuse. 
Moulton*  recorded  the  progress  of  improvement  in  two  marked 
cases  of  this  amblyopia.  In  cases  of  congenital  or  infantile 
cataract  operated  upon  in  youth  or  early  adult  life  the  result  is 
very  poor.  Some  of  our  patients  could  only  see  moving  bodies 
afterwards. 

Coloured  Vision. — Erythropsia  is  an  occasional  complaint 
of  aphakic  patients  after  exposure  to  bright  light,  especially, 
perhaps,  in  cases  where  a  broad  iridectomy  has  been  made. 
We  saw  almost  nothing  of  it  in  Bombay,  probably  because  the 
wards  were  rather  dark,  and  the  patients  were  all  supplied 
with  cheap  dark  glasses  and  shades  on  dismissal.  It  is  caused 
mainly  by  the  ultra-violet  rays,  for  which  the  lens  has  a  high 
absorptive  power. 

Cyanopsia  has  been  comparatively  seldom  recorded.  This  is 
possibly  because  it  is  a  very  transient  condition.  Elliot,  in 
Madras,  found  that  slightly  more  than  half  of  his  patients  had 
blue  vision  for  some  period  of  their  stay  in  hospital. f  Enslin 
has  also  drawn  attention  to  this  affection  after  cataract  ex- 
traction. Maddox  suggests  that  as  most  cataractous  nuclei 
have  a  yellowish  or  amber  tint,  the  sudden  removal  of  this 
coloured  medium  is  sufficient  to  flood  the  retina  with  the 
complemental  colour. 

*  Oph.  Record,  April,  1903. 

t   The  Ophthalmoscope,  iv  (1906),  15. 


CHAPTER    III 

EXPULSIVE    HAEMORRHAGE.     VITREOUS 
ACCIDENTS 

In  the  foregoing  pages  numerous  difficulties  and  accidents 
have  been  set  forth,  distributed  according  to  the  stage  of 
the  operation  which  they  comphcate.  There  are  still  two 
grave  complications  which  belong  to  no  particular  step  of 
the  operation,  and  which  may  occur  even  later  during  the 
healing  period.  These  complications,  expulsive  haemorrhage 
and  prolapse  or  loss  of  vitreous,  are  therefore  to  be  con- 
sidered now.  The  trouble  with  vitreous  is  generally  a 
consequence  of  one  of  the  mistakes  or  difficulties  already 
dealt  with. 

EXPULSIVE    HEMORRHAGE. 

By  this  term  is  understood  bleeding  from  the  fundus  suffi- 
cient to  expel  part  or  the  whole  of  the  contents  of  the  globe 
through  the  wound.  It  is  also  known  as  '  essential '  and  '  retro- 
choroidal '  haemorrhage.  It  is,  fortunately,  a  rare  accident. 
Formerly,  in  nearly  3,000  extractions  I  had  only  met  with  it 
twice,  but  now,  with  the  total  only  about  5,000,  I  have  to 
record  seven  typical  and  two  incompletely  expulsive  cases. 
De  Wecker  reported  eight  haemorrhages  in  3,000  operations, 
Sattler  *  only  four  cases  in  over  3,000  operations. 

The  bleeding,  also  seen  after  iridectomy  for  glaucoma,  has 
been  shown  by  anatomical  investigation  to  come  from  choroidal 
veins.  The  blood,  collecting  first  between  the  sclerotic  and  the 
choroid,  ruptures  the  latter.  The  accident  most  frequently  occurs 

"^  A.f.  O.,  xlvi  (1898),  235. 
160 


Expulsive  Haemorrhage  i6i 

during  operation  or  immediately  after  it,  but  it  may  happen  at 
any  time  during  the  first  twenty-four  hours  after  operation, 
and  has  been  known  as  late  as  ten  days  afterwards.*  In  the 
first  case  the  corneal  flap  is  slowly  pressed  forward,  vitreous 
presents  in  the  wound  and,  after  rupture  of  the  zonule,  escapes. 
Blood  soon  follows,  and  often  after  the  expulsion  of  the  whole 
or  greater  part  of  the  vitreous,  detached  portions  of  retina  and 
choroid  may  be  seen.  Occasionally,  however,  the  appearance 
of  blood  in  the  wound  is  the  first  indication  of  trouble.  When 
the  haemorrhage  takes  place  later,  we  find  the  dressings  soaked 
with  blood,  the  lids  pressed  forward,  and  protruding  from  the 
widely  gaping  wound  a  large  clot  of  blood.  The  eye  filled 
with  clot  feels  hard,  and  perception  of  light  is  lost.  The  onset 
may  be  marked  by  acute  pain,  or  there  may  be  merely  a  feeling 
of  tension  or  heat,  or  no  particular  feeling  of  discomfort  at  all. 
There  may  be  vomiting,  and  epileptic  seizure  has  been  recorded 
(Berry). 

The  bleeding  sometimes  stops  early.  At  other  times  there 
may  be  continued  or  repeated  oozing  for  days,  in  spite  of  a 
pressure  bandage.  The  globe  afterwards  shrinks.  In  former 
times  panophthalmitis  sometimes  developed. 

In  some  cases  disease  of  choroidal  blood-vessels  has  been 
found — dilatation,  degeneration,  and  infiltration  of  the  walls  of 
the  veins,  also  sclerotic  changes  in  the  arteries.  But  in  other 
eyes  no  evidences  of  disease  have  been  found  in  the  blood-vessels. 

The  accident  is  recognized  as  perhaps  the  chief  danger  in 
extracting  the  lens  from  a  glaucomatous  eye  (one  of  our  cases 
was  thus  accounted  for).  Venous  congestion  from  vomiting, 
coughing,  or  straining  has  been  blamed  as  a  partial  cause,  also 
strong  pressure  upon  the  eye  during  operation.  Noyes  and  da 
Gama  Pinto  reported  the  occurrence  of  the  accident  in  highly 
myopic  eyes,  probably  from  disease  of  the  choroid  (see  also  our 
case  mentioned  in  the  footnote  to  p.  74).  Haemophilia  was 
mentioned  in  one  case  by  da  Gama  Pinto.  Often  no  explana- 
tion of  the  complication  can  be  found.!  And  possibly  the  old 
idea  that  the  bleeding  was  a  result  of  loss  of  vitreous  may 

*  White  Cooper,  quoted  by  Terrien,  '  Chirurgie  de  I'oeil,'  p.  172. 

t  Sattler  thought  that  the  accident  was  rarer  in  the  old  days  before 
cocain  was  used.  But  it  has  been  suggested  that  some  of  the  cases 
were  then  reported  differently,  being  attributed  to  vomiting  due  to  the 
anaesthetic. 

II 


1 62  Cataract  Extraction 

sometimes  be  partially  correct.*  In  patients  who  have  had 
both  eyes  operated  upon  the  disaster  has  usually  been  observed 
only  in  one  eye. 

One  very  occasionally  sees  inexplicable  escape  of  vitreous, 
apparently  spontaneous,  during  operation — so  suggestive  of  the 
onset  of  deep  haemorrhage.  But  no  blood  appears,  and  the 
eyes  do  perfectly  well  afterwards,  and  one  may  fail  to  find  any 
choroidal  detachment  or  other  sign  of  fundus  haemorrhage. 
Possibly,  however,  the  presence  of  after-cataract  may  at  times 
account  for  this  negative  finding. 

There  are  also  rare  cases  of  less  profuse  haemorrhage,  in- 
completely '  expulsive,'  in  which  some  sight  may  be  retained. 
In  one  of  our  cases  the  corneal  flap  was  slowly  pressed  forward 
at  the  close  of  the  operation.  Then  followed  rupture  of  zonule 
and  large  loss  of  vitreous,  but  no  blood  appeared  in  the  wound. 
A  month  later  the  patient  could  count  fingers  at  2  feet  with 
this  eye,  but  later  the  vision  fell  to  moving  bodies  only^  and  the 
eyeball  was  shrinking.  Again,  in  a  Czermak's  lower  subcon- 
junctival operation  haemorrhage  occurred  large  enough  to 
open  the  wound  and  raise  the  overlying  conjunctiva,  but  there 
was  no  expulsion  of  vitreous.  The  pupil  became  closed, 
though  the  iris  remained  bright.  An  irido-capsulotomy,  nearly 
a  month  later,  failed  to  do  good.  The  opening  became  occupied 
by  blood,  apparently  from  the  vitreous.  Later  the  eye  was 
softening  and  the  field  of  projection  of  light  was  contracting. 
A  case  of  haemorrhage  complicating  an  iridectomy  operation 
for  chronic  glaucoma  in  our  practice  is  also  of  interest  here. 
It  was  profuse  enough  to  expel  the  lens  with  a  quantity  of 
vitreous  and  to  distend  the  wound.  But  the  patient  a  month 
later  could  count  fingers  at  9  inches.  Before  operation  he 
could  count  them  at  2  feet.  Such  cases  link  the  more  profuse 
and  uncontrollable  haemorrhages  with  the  small  fundus  haemor- 
rhages sometimes  produced  by  operation  in  advanced  glaucoma, 
and  with  those  responsible  for  the  condition  '  malignant  glau- 
coma.' 

*  For  example,  in  one  of  our  cases  a  large  loss  of  vitreous  followed 
an  attempt  to  dislodge  a  bit  of  cortex  by  external  pressure,  but  the 
flow  of  vitreous  appeared  to  be  at  an  end  when  the  lids  were  closed. 
Half  an  hour  later  the  patient  was  vomiting,  and  had  considerable 
pain,  and  some  little  time  afterwards  the  dressing  was  found  soaked 
in  blood. 


Expulsive  Haemorrhage  i6 


o 


H.  Becker*  reported  a  case  of  arterial  haemorrhage,  ap- 
parently not  expulsive,  which  began  during  operation  and 
resisted  treatment  (including  evisceration  and  packing  and 
cauterization  of  the  central  artery)  for  four  weeks. 

Treatment. — Ordinarily  a  pressure  bandage  is  applied, 
after  excision  of  any  portions  of  choroid  or  retina  lying  in  the 
wound.  If  the  bleeding  does  not  quickly  cease,  a  hypodermic 
injection  of  20  minims  of  adrenalin  chloride  solution  (Parke 
Davis's,  I  in  1,000)  may  be  given,  and  15  grains  of  calcium 
chloride  administered  every  hour  for  some  hours.  This  proved 
sufficient  in  all  our  cases,  but  various  other  measures  have 
been  found  advisable  or  necessary  at  times.  Ice  has  been 
applied  and  morphia  injections  given,  and  the  upright  position 
assumed.  Trousseau  advised  the  application  of  a  sclero- 
corneal  suture.  Enucleation  has  been  frequently  performed. 
Formerly  this  was  done  more  often  than  now,  partly  with  the 
object  of  avoiding  panophthalmitis.  Evisceration  and  packing 
with  gauze  or  gelatin  has  been  done  also. 

Prophylaxis. — If  it  be  decided  to  extract  a  cataract  from  the 
fellow  eye  after  one  eye  has  been  lost  from  expulsive  haemor- 
rhage, both  general  and  local  precautions  are  indicated. 

1.  Preliminary  general  treatment  must  be  directed  to  lessen 
any  circulatory  disturbances  and  to  lower  the  blood-pressure. 
Tersonf  recommends  as  preparation  a  suitable  diet,  little  to 
drink,  purgation,  iodides,  and  tinctura  veratri  viridis,  also 
chloral  at  night. 

Abadie  suggests  egotin  injection,  and  for  twenty-four  hours 
from  the  time  of  operation  compression  of  the  carotid. 

2.  A  preliminary  iridectomy  is  indicated,  though  in  spite  of 
this  haemorrhage  has  occurred  at  the  subsequent  extraction. 
Instead  of  the  ordinary  extraction,  discission  and  linear  extrac- 
tion have  been  performed,]:  discission  of  a  fully  ripe  cataract 
giving  rise  to  little  trouble  in  the  eye.  The  cataract  incision 
must  be  made  slowly,  in  order  that  the  ocular  tension  may  not 
be  diminished  suddenly.  And  perfect  rest  must  be  maintained 
afterwards. 

*  Ref.  A./.  A.,  September,  1905. 
+  Arch.  dOphth.,  xiv  (1894),  no. 
X  Peirone,  A.f.  A..,  xxxviii  (1899),  163. 


II — 2 


164  Cataract  Extraction 

VITREOUS   ACCIDENTS. 

The  escape  of  vitreous  humour  from  the  eye  has  already 
received  frequent  mention.  It  predicates  a  perforation  or 
rupture  of  the  supporting  diaphragm  formed  of  suspensory 
ligament  and  lens  capsule,  also  of  the  hyaloid  membrane. 
In  addition,  an  expelling  force  is  needed.  This  is  generally 
external  pressure,  by  instrument,  finger,  or  lids,  or  less 
obviously  by  action  of  the  extrinsic  muscles  upon  the  eye ; 
but  occasionally  the  pressure  is  from  within,  from  elasticity 
of  the  sclerotic,  contraction  of  the  tensor  choroidese  (?),  or 
intraocular  haemorrhage. 

Prolapse  and  incarceration  of  vitreous  in  the  wound, 
distinct  from  the  actual  flowing  away  of  the  humour,  are 
minor  grades  of  vitreous  accident,  but  not  necessarily  of 
diminished  gravity  as  regards  the  result.  So  far  as  one 
can  judge  they  depend  upon  rupture  of  zonule  or  capsule 
alone,  the  hyaloid  membrane  remaining  intact.  They 
are  comparatively  infrequent  except  as  brief  preliminaries 
to  expulsion.  The  whole  length  of  the  incision  may  be 
forced  open  by  a  narrow  and  low  protrusion  of  vitreous 
showing  no  immediate  tendency  either  to  recede  or  to 
enlarge.  More  commonly  the  protrusion  steadily  increases 
in  height  and  width,  still  further  separating  the  wound 
margins,  up  to  a  certain  point  when  it  suddenly  collapses 
more  or  less  and  vitreous  flows  away.  The  rupture  of  an 
invisible  containing  membrane  is  the  obvious  explanation 
of  the  occurrence.  Should  a  simple  prolapse  remain 
stationary  the  same  partial  or  complete  collapse,  with  flow 
of  vitreous,  may  be  brought  about  by  puncture  with  a  knife 
or  by  partial  excision  of  the  prominence  with  scissors. 
Occasionally  the  vitreous  may  present  at  the  wound  with- 
out actually  entering  it ;  the  corneal  flap  is  pressed  for- 
ward, causing  the  wound  to  gape  a  little. 


Vitreous  Accidents  165 

The  appearance  of  vitreous  in  the  incision  is  in  many 
cases  preceded  by  a  characteristic  deepening  of  the  anterior 
chamber,  from  vitreous  entering  through  the  pupil  or 
through  the  coloboma.  Very  occasionally  the  humour 
may  pass  into  the  chamber  thus  without  reaching  the 
wound.  In  other  cases  the  anterior  chamber  remains 
empty,  and  the  iris  is  forced  forward  into  the  wound.  If 
an  iridectomy  has  not  been  made,  the  bulging  iris  retains 
the  vitreous  until  the  pupil  dilates  so  widely  that  the 
whole  breadth  of  the  upper  portion  of  iris  lies  exposed  in 
the  section,  allowing  the  humour  to  pass  out  in  front  of  it. 
The  deepened  chamber  seems  more  likely  to  be  met  with 
when  the  zonule  ruptures  below,  while  the  vitreous  seems 
more  likely  to  press  the  iris  forward  when  the  rupture 
occurs  close  to  the  wound  above. 

Vitreous  expulsion  most  often  accompanies  or  follows 
immediately  the  delivery  of  the  lens.  The  escape  may, 
however,  take  place  as  soon  as  there  is  a  large  enough 
opening  made  in  the  eyeball,  or  it  may  begin  slowly  with- 
out obvious  cause  just  after  the  operation  is  finished. 
Rarely  it  may  occur  later  during  the  healing  process 
(Chapter  V). 

Since  a  flow  of  vitreous  may  possibly  continue  or  recur 
after  the  eyelids  have  been  closed  and  the  dressing  applied, 
estimates  of  the  quantity  lost  can  only  be  tentative.  In 
any  case  they  are  very  rough.  Smith's  losses  at  Jullundur 
are  said  to  have  consisted  usually  of  only  a  small  *  bead ' 
of  humour.  In  my  experience  quite  small  losses  are  the 
exception.  The  amount  may  vary  up  to  about  two-thirds 
of  the  total  humour.  Where  the  vitreous  is  of  very  fluid 
consistence  some  of  it  may  pass  through  the  wound  with- 
out being  noticed.  The  only  evidence  may  be  a  slight 
gumminess  of  the  fluid  in  the  conjunctival  sac.  At  times, 
therefore,  one  may  feel  uncertain  as  to  whether  a  small 


1 66  Cataract  Extraction 

gush  of  vitreous  has  taken  place  or  not.  Not  very  un- 
commonly in  large  losses,  the  portion  which  comes  first  is 
of  more  or  less  reduced  consistence,  and  it  is  followed  by 
firmer  normal  material.  In  some  cases  the  flow  may  prove 
to  be  in  no  degree  controllable  until  a  considerable 
quantity  of  humour  has  been  lost.  These  eyes  include 
some  in  which  no  other  evidence  of  '  vitreous  tension  '  has 
been  observed.  On  the  other  hand,  from  slack  and  rigid 
eyeballs  the  humour  has  to  be  actually  pressed  out,  and 
ceases  to  escape  as  soon  as  external  pressure  is  removed. 

Causes. — In  ordinary  cataract  extraction  the  complica- 
tion may  be  due  to  fault  of  the  operator  or  assistant,  or  of 
the  patient,  or  of  neither.  The  cause  is  often  quite 
obvious.  Or  again,  one  may  feel  at  a  loss  to  hazard  even 
a  conjecture  as  to  the  offending  conditions  or  mechanism. 

Of  pre-existing  conditions,  the  only  one  quite  unassail- 
able as  constituting  usually  a  sufficient  excuse  for  the 
accident  (though  even  here  the  accident  is  not  always 
inevitable)  is  dislocation  of  the  lens.  Also  there  are  cases 
of  diseased  eyes  where  dislocation,  due  to  weak  suspensory 
ligament  and  perhaps  fluid  vitreous,  occurs  during  the 
making  of  the  incision,  however  gently  it  be  made.  But 
the  tremor  of  a  Morgagnian,  or  formerly  Morgagnian, 
cataract  is  not  to  be  accepted  as  conclusive  evidence  of 
conditions  more  than  feebly  predisposing  to  accident. 
Exceptional  gentleness  and  correct  procedure  are  com- 
monly effective  in  preventing  complication  in  these  cases. 
In  similar  manner,  by  prompt  recognition,  *  vitreous 
tension '  is  generally  deprived  of  its  peculiar  danger. 
And  the  special  tendency  to  rupture  of  zonule  in  eyes 
with  much  retracted  conjunctival  fornices  applies  only  to 
extraction  by  ordinary  section,  and  not  to  the  subcon- 
junctival operations.  In  eyes  apparently  sound  apart 
from    the   cataract,   occasional   difficulty  in   determining 


Vitreous  Accidents  167 

the  real  origin  of  vitreous  complication  may  possibly  be 
explained  sometimes  by  the  suggestion  that  the  main 
cause  is  separated  from  the  result  by  a  definite  interval  of 
time.  Damage  done  to  zonule  during  the  earlier  stages 
of  operation  may  not  be  made  known  until  pressure  is 
apphed  for  the  expulsion  of  the  lens  or  of  cortical  remains. 
Or  predisposition  to  accident  may  have  been  introduced 
by  too  deep  a  counter-puncture  and  too  peripheral  a 
section,  depriving  the  zonule  of  the  support  usually 
afforded  by  the  peripheral  strip  of  cornea  and  by  the 
sclerotic. 

The  loss  of  the  support  of  the  iris  after  a  coloboma 
has  been  made  has  also  been  claimed  as  slightly  facili- 
tating rupture  of  the  zonule.  And  very  prominent  eyes — 
e.g.,  in  exophthalmos  and  high  myopia — are  more  liable 
to  vitreous  accident  in  that  the  lids  contracting  upon 
the  globe  obtain  a  greater  purchase  upon  it. 

Among  the  more  obvious  and  immediate  excitants 
distributed  through  the  pages  of  Chapter  II  may  be 
recapitulated  : — a  dragging  incision  ;  too  firm  or  too  heavy 
fixation  ;  slipping  of  speculum  ;  drag  or  pressure  of  cysti- 
tome  or  of  capsule  forceps ;  sudden  upward  movement  of 
the  eye  with  an  instrument  in  the  anterior  chamber,  or 
with  curette  resting  above  the  wound,  or  with  the  upper 
lid  insufficiently  elevated ;  incautious  pressure  in  expelling 
lens  or  cortex  ;  difficulties  in  connexion  with  the  toughened 
capsule  of  overripe  cataracts ;  also  painful  or  startling 
occurrences  calculated  to  excite  spasm  of  the  orbicularis, 
such  as  a  prick  with  the  point  of  the  knife  near  the  inner 
canthus,  or  spurt  of  fluid  upon  the  face  from  the  irri- 
gator. 

There  are  puzzling  spontaneous  expulsions  of  vitreous 
about  the  close  of  the  operation  already  referred  to. 
Those  which  I  have  seen  have  not  been  in  eyes  with 


1 68  Cataract  Extraction 

noticeable  vitreous  tension.  They  at  once  suggest  the 
onset  of  expulsive  haemorrhage,  but  the  haemorrhage  does 
not  take  place,  and  the  eyes  commonly  see  well  after- 
wards. In  Bombay  we  have  somewhat  neglected  our 
opportunities  of  examining  these  eyes  for  choroidal 
detachment  later,  such  as  would  suggest  that  the  vitreous 
expulsion  had  been  caused  by  limited  retro-choroidal 
haemorrhage.  Spasm  of  the  tensor  oculi  muscle  has  been 
mentioned  as  a  possible  cause  by  Nicati. 

Prevention. — From  the  very  varied  means  of  production 
of  the  complication  it  is  obvious  that  endeavours  to  reduce 
its  frequency  must  be  comprehensive. 

1.  Among  the  more  essential  precautionary  measures  is 
the  proper  control  of  nervous  patients.  Excitable  patients 
must  be  quieted  by  bromide  or  other  sedative,  by  com- 
bining adrenalin  with  the  cocain  instilled,  and  by  the 
surgeon's  influence  during  operation.  A  trained  assistant 
is  important  to  take  charge  of  the  stop-speculum,  which 
must  be  removed  promptly  if  the  patient  shows  signs  of 
losing  control  over  his  orbicularis  muscle.  If  the  patient 
fails  to  pass  the  prescribed  tests  beforehand,  a  subcon- 
junctival operation  should  be  performed. 

2.  The  latter  method  should  be  adopted  also  when 
conditions  present  in  the  eye  predispose  to  vitreous 
accident  (Chapter  IV). 

3.  In  psLTticular  gentleness  must  characterize  the  surgeon's 
procedure  throughout.  The  remarks  made  in  Chapter  II 
must  be  borne  in  mind  regarding  dragging  incision,  over- 
firm  fixation,  cautious  capsulotomy,  and  especially  slow 
expression  of  the  lens  and  careful  dealing  with  cortex. 

4.  Watchfulness  and  caution  are  mainly  matters  of 
experience,  to  promptly  detect  and  remove  direct  causes  of 
accident  and  excitants  of  lid  spasm,  and  to  guard  against 
injury  by  sudden  movements  of  the  globe.     The  situation 


Vitreous  Accidents  169 

must  be  saved  if  necessary  by  bringing  the  operation  to  a 
close  without  completing  the  '  toilet '  of  the  eye. 

An  additional,  but  an  unfair,  means  of  reducing  one's 
percentage  of  accident  would  be  the  rejection  of  com- 
plicated cataracts  and  dislocated  lenses. 

Our  vitreous  losses  in  Bombay  in  1,262  flap  extractions 
performed  during  1905  and  1906  totalled  thirty-eight — i.e., 
3  per  cent.  (Cases  are  not  included  in  which  the  loss  was 
preliminary  to  expulsive  haemorrhage.)  Of  the  thirty-eight, 
sixteen  escapes  may  be  classed  as  avoidable,  seven  excusable, 
and  fifteen  unavoidable. 

For  the  sixteen  avoidable  accidents  I  accept  the  responsibility. 
Eight  of  the  losses  were  caused  by  the  patients  squeezing  their 
lids  forcibly  together.  But  this  might  have  been  prevented  in 
many  cases  by  securing  more  complete  anaesthesia  with  adre- 
nalin and  cocain,  and  by  other  precautions.  Six  of  the  accidents 
were  due  to  ill-performed  operations  by  downward  section, 
three  by  ordinary  flap  incision,  three  by  Czermak's  scissor 
method.  I  was  at  the  time  inexperienced  in  both  of  these 
methods.  Another  loss  was  ascribed  to  the  use  of  a  rather 
blunt  knife,  and  another  to  accidental  puncture  of  the  posterior 
capsule  (in  a  case  of  traumatic  cataract). 

The  seven  excusable  accidents  were  all  in  connexion  with 
toughened  capsules  of  overripe  cataracts.  Against  these  may 
be  set  other  extractions,  intracapsular  and  otherwise,  where 
from  extreme  overripeness,  dislocation,  and  so  on,  loss  of 
vitreous  was  anticipated,  but  was  avoided. 

The  fifteen  unavoidable  cases  included  no  less  than  eight 
spontaneous  escapes,  and  seven  others  accounted  for  variously, 
by  existing  dislocation  of  the  lens  (three  cases),  ectopia  lentis 
(one),  occluded  pupil  with  fluid  vitreous  (one),  and  atrophic 
zonule  (two  cases ;  in  one  the  vitreous  escaped  during  the 
making  of  the  section,  and  in  the  other  the  lens  became 
dislocated  during  the  cutting). 

Thus  the  losses  might  with  extreme  care  have  been  possibly 
reduced  by  about  one-third  of  the  total.  The  actual  figures, 
however,  are  not  of  much  value  for  application  elsewhere.  So 
much  depends  upon  the  class  of  patients,  and  the  proportion 
of  diseased  eyes  and  overripe  cataracts.     It  may  be  safely  laid 


170  Cataract  Extraction 

down  that  in  countries  where  cataract  is  commonest  the 
proportion  of  complicated  cataracts  will  be  lowest.  On  the 
other  hand,  in  India  the  cataracts  are  very  much  more  often 
allowed  to  become  overripe  than  in  Europe  and  America. 

Elliot*  (Madras)  had  only  27  per  cent,  of  vitreous  losses  in 
2,000  consecutive  extractions.  Maynard  |  (Calcutta)  reported 
6-3  per  cent,  of  losses  in  an  earlier  series  of  1,000  operations, 
4*3  per  cent,  in  a  later  similar  series. 

Management  of  Cases. — When  vitreous  escape  is  due 
to  spasm  of  the  lids,  usually  our  first  concern  is  to  remove 
the  speculum  before  further  harm  can  be  done.  But  it  is 
often  necessary  to  adjust  the  margins  of  the  incision. 
This  may  sometimes  be  done  with  the  speculum  still 
in  position,  otherwise  with  the  lids  controlled  by  the 
assistant's  fingers  or  with  Desmarres'  retractor.  Where  a 
large  loss  has  been  occasioned  by  external  pressure  alone 
there  is  more  or  less  collapse  of  the  globe.  The  corneal 
lip  of  the  incision  generally  falls  back  behind  the  scleral 
lip ;  or  it  may  override  the  latter  considerably.  In  the 
former  case  the  conjunctival  flap  must  be  drawn  up  over 
the  peripheral  lip.  Some  surgeons  have  filled  the  anterior 
chamber  with  saline  solution,  to  obtain  better  adjustment 
of  the  wound  margins,  but  it  is  unnecessary.  In  tenser 
eyeballs  the  wound  may  still  remain  occupied  by  a 
projecting  mass  of  firm  vitreous,  just  as  when  prolapse  alone 
occurs  without  loss.  It  is  advisable  to  cut  away  some  of 
this  projecting  material  with  scissors.  This  does  not  lead 
to  immediate  coaptation  of  the  wound  margins,  but  in  my 
experience  it  secures  their  readjustment  within  twenty- 
four  hours.  The  snipping  away  of  a  simple  prolapse  is 
imperative.  This  must  be  done  as  quickly  as  possible, 
and  the  patient  is  not  asked  to  turn  his  eye  strongly 
downwards,  lest  additional  expulsion  of  vitreous  be  thus 

*  Personal  communication. 

t  Ind.  Med.  Gazette^  xli  (1906),  315. 


Vitreous  Accidents  171 

brought  about  (through  the  pull  of  the  recti  muscles 
tending  to  open  the  wound,  and  their  pressure  tending  to 
expel  vitreous). 

Should  a  wide  prolapse  of  iris  lie  in  the  wound  also, 
much  of  this  may  be  excised  at  the  same  time,  but  usually 
without  the  aid  of  iris  forceps.  The  globe  cannot  be 
fixed  with  forceps,  and  if  not  kept  quiet  by  the  patient  it 
may  be  impossible  to  remove  the  iris.  Should  the  vitreous 
have  escaped  before  an  iridectomy  has  been  made,  and 
should  the  iris  have  been  pressed  back  within  the  globe  by 
the  humour  passing  in  front  of  it,  the  iris  should  not 
be  interfered  with.*  There  is  little  or  no  risk  of  subse- 
quent prolapse.  The  upper  portion  of  the  iris  may  have 
already  receded  partly  or  completely  behind  the  scleral 
margin. 

A  narrow  incarceration  or  mere  presentation  of  vitreous 
causing  the  wound  to  gape  but  slightly  is  left  in  the  hope 
that  it  will  recede. 

Both  eyes  are  bandaged  carefully,  without  pressure  upon 
the  operated  one.  The  greatest  care  is  necessary  at  the 
earlier  dressings  not  to  cause  a  recurrence  of  vitreous 
escape.  The  eyelids  need  be  scarcely  separated,  and  the 
lower  lid  must  be  kept  well  away  from  the  eye.  After 
several  days,  if  the  wound  is  still  not  closed  and  the  eye  is 
no  longer  quite  soft,  the  application  of  a  pressure  bandage 
is  indicated. 

Consequences. — In  most  cases  there  is  next  day  no 
longer  any  evidence  of  the  mischance ;  the  healing  goes  on 
normally  and  the  consequences  are  nil.  Very  occasionally 
the  wound  remains  open  with  vitreous  impacted  in  it.  If 
the  wound  margins  are  only  a  little  separated,  their 
approximation   generally  takes   place   under    a    pressure 

*  The  use  of  a  sharp  hook  has  been  recommended  for  drawing  out 
the  iris  for  excision. 


172  Cataract  Extraction 

bandage.  But  sometimes  this  does  not  happen,  and  in 
the  case  of  a  wide  incarceration  is  not  to  be  expected.  The 
exposed  vitreous  soon  becomes  opaque  from  infiltration, 
and  later  acquires  firmness  from  the  formation  of  fibrous 
tissue  in  it.  Thus  cicatrization  progresses  with  the 
corneal  flap  considerably  displaced.  A  high  degree  of 
astigmatism  persists.  The  anterior  chamber  may  fail  to 
reform  for  a  long  time,  and  opacity  of  the  posterior  layers 
of  the  cornea — *  contact  keratitis  ' — may  develop.  And 
opaque  bands  may  spread  from  the  impacted  tissue  into 
the  vitreous,  further  interfering  v/ith  vision,  and  tending 
to  draw  the  retina  forward  and  to  cause  detachment. 

The  exposure  of  the  vitreous,  and  later,  the  ectatic  scar 
which  develops,  must  open  the  way  more  or  less  per- 
manently for  possible  infection  of  the  eye.  Even  when 
the  wound  is  found  well  adjusted  at  the  first  dressing, 
it  may  have  been  kept  open  by  vitreous  for  some  hours 
after  the  operation.  It  is  only  fair  to  attribute  to  this 
source  some  of  the  infective  inflammations  which  follow 
early  or  late.  For  experience  in  discission  operations  has 
shown  that  numbers  of  eyes  have  been  lost  by  suppuration 
through  impaction  of  minute  threads  of  vitreous  in  needle 
punctures.  Bacterial  invasion  of  the  eye  may  be  further 
aided  by  the  healing  of  iris  in  the  wound,  prolapsed 
or  incarcerated.  Even  where  an  iridectomy  has  been 
performed  impaction  of  iris  frequently  occurs  at  the  two 
ends  of  the  incision.  One  is  afraid  to  attempt  excision  of 
the  displaced  iris  on  account  of  the  risk  of  causing 
renewed  loss  of  vitreous. 

It  is  said  that,  apart  from  the  risk  of  secondary  infection, 
the  prognosis  of  cases  with  vitreous  healing  in  the  wound 
is  bad,  and  that  many  of  the  cases  end  in  atrophy  of  the 
globe.* 

*  Czermak,  '  Die  Augen.  Op.,'  S.  943. 


Vitreous  Accidents  173 

Impaction  of  firm  vitreous  in  the  wound  is  seldom  seen  after 
loss  during  operation  if  the  projecting  mass  has  been  rather 
freely  cut  away.  I  had  gained  an  impression  from  Bombay 
work  that  incarceration  during  the  healing  process  was  to  be 
found  only  in  cases  where  vitreous  had  not  actually  escaped, 
and  where,  therefore,  the  hyaloid  membrane  might  be  still 
intact.  Elliot  (Madras)  has  kindly  given  me  his  experience 
on  this  point.  He  had  fifty-eight  vitreous  escapes  in  2,000 
extractions.  In  eight  of  these  cases  the  section  gaped  for 
variable  periods  afterwards.  Among  these  cases  one  pupil 
became  occluded,  and  there  were  two  other  very  poor  visual 
results.  Besides  these  accidents,  there  were  six  other  cases  in 
which  impaction  occurred  at  the  time  of  operation  or  later, 
though  there  was  no  vitreous  escape.  These  eyes  all  obtained 
good  vision,  and  a  finally  closed  section  is  mentioned  in  all 
but  one  case,  in  which  a  hypopyon  formed. 

Many  cases  in  which  the  wound  heals  up  normally  show 
an  evidence  of  anchoring  of  vitreous  to  the  scar.  Possibly 
in  these  cases  fine  threads  or  films  of  vitreous  tissue 
become  incorporated  in  the  scar.  The  evidence  consists 
in  a  striking  and  characteristic  enlargement,  distortion,  and 
displacement  of  the  pupil,  without  impaction  of  the  iris  or 
adhesion  of  the  iris  to  the  wound.  It  is  mostly  seen  after 
large  losses,  but  I  have  seen  medium  and  minor  grades  of 
the  abnormality  where  no  vitreous  accident  of  any  kind 
had  been  noticed  at  the  time  of  operation.  Probably  in 
at  least  some  of  these  cases  expulsion  of  vitreous  may 
have  taken  place  after  the  application  of  the  bandage. 

In  the  typical  condition  as  seen  after  large  losses  the 
appearance  is  as  though  an  enormous  iridectomy  had  been 
made.  It  is  the  same  whether  an  iridectomy  has  been 
actually  performed  or  not.  The  upper  half  of  the  iris 
has  disappeared,  retracted  behind  the  scleral  margin.  It 
can  be  seen,  however,  by  focal  illumination,  narrowed, 
immobile,  and  irresponsive  to  eserin. 

The  pupillary  margin  of  the  lower  half  of  the  iris  arches 


174  Cataract  Extraction 

across,  only  slightly  curved,  about  or  above  the  middle  of 
the  cornea,  to  disappear  at  either  end  behind  the  sclera 
(Fig.  73).     It  reacts  but  little  or  not  at  all  to  light. 

In  the  minor  grades  of  abnormality  the  retraction  of 
the  iris  is  less  complete,  and  the  widening  of  the  pupil 
laterally  is  not  extreme.     The  upper   narrowed  strip  of 


Fig.  72)' — Distorted  Pupil. 

iris  lies  behind  the  cornea.  Even  here  the  division 
between  the  two  portions  of  iris  may  be  quite  sharp,  though 
I  do  not  know  if  it  is  always  so. 

In  some  cases,  at  least,  the  plane  of  the  atrophic  iris 


Fig.  74.— Distorted  Pupil. 

is  distinctly  posterior  to  the  scar  line.  But  in  old  cases 
where  the  upper  part  of  the  iris  has  practically  disappeared, 
the  condition   may  perhaps  closely  approximate  to  that 


Fig.  75. — Distorted  Pupil. 

brought  about  by  adhesion  of  capsule  and  of  iris  to  the 
scar. 

Though  the  retraction  of  iris  may  be  well  marked  at  the 
first  examination  twenty-four  hours  after  operation,  the 
portion  of  iris  then  involved  may  be  only  small.  It  may 
increase  gradually  later,  with  progressive  widening   and 


Vitreous  Accidents  175 

drawing  up  of  the  pupil.  And  the  narrowed  iris  in  the 
course  of  months  may  become  still  narrower  and  markedly 
atrophic,  and  probably  may  disappear  altogether. 

Fig.  74  (a)  shows  a  condition  seen  eleven  days  after  operation 
on  the  discharge  of  the  patient  from  hospital.  Two  months 
later  this  condition  had  changed  to  that  shown  in  Fig.  74  (b). 
The  remains  of  iris  above  were  almost  unrecognizable — merely 
a  narrow,  pale  greyish  band,  with  its  lower  margin  dark 
towards  either  end.  Fig.  75  (a)  shows  a  condition  of  pupil 
found  on  the  first  day  after  an  extraction  by  Czermak's  lower 
section.  There  had  been  no  presentation  or  loss  of  vitreous, 
but  there  had  been  evidently  rupture  of  the  zonule  above,  for 
the  upper  edge  of  the  capsule  was  to  be  seen  later  in  the  dis- 
torted pupil.  At  the  time  of  discharge  from  hospital  the 
distortion  and  enlargement  of  the  pupil  had  increased,  as 
shown  in  Fig.  75  (b). 

Though  Pope  and  Elliot  (both  of  Madras)  have  referred 
to  this  distortion  of  pupil,  the  only  description  of  it,  so  far 
as  I  know,  has  been  in  my  '  Practical  Details  of  Cataract 
Extraction.' 

The  fixation  of  the  vitreous  to  the  scar  is  supposed  to 
tend  towards  later  detachment  of  the  retina.  But  detach- 
ment may  follow  also  without  this  adhesion.  This  is  the 
result  which  we  fear  most  after  large  vitreous  loss.  But 
often  it  does  not  take  place  after  very  large  escape,  even 
from  myopic  eyes.  The  connexion  between  vitreous  loss 
and  retinal  detachment  is  undoubted,  but  we  need  much 
more  exact  knowledge  of  the  subject  than  we  now  possess. 
Sometimes  after  vitreous  expulsion  the  tension  of  the  eye 
is  late  in  being  re-established.  And  after  the  largest 
losses,  especially  repeated  losses,  the  eyes  may  become 
rapidly  atrophic.  One  fears  a  bad  result  from  vitreous 
accident  in  the  not  infrequent  cases  in  which  long  floating 
threads  of  opacity  are  found  in  the  vitreous  at  the  time  of 
discharge. 


176  Cataract  Extraction 

In  a  recent  Bombay  case  in  which  there  was  detachment  of 
the  retina  and  low  tension  after  a  vitreous  escape,  the  clear  area 
of  the  coloboma  above  an  opaque  patch  of  capsule  occupying 
the  pupil  became  slowly  covered  by  a  grey  exudative  film, 
though  there  was  no  ciliary  injection  or  other  evidence  of 
inflammation.  The  edges  of  the  wound  were  in  good 
apposition. 

Opinions  are  widely  divided  as  to  the  gravity  of  the 
dangers  from  loss  of  vitreous.  Smith  of  Jullundur,  the 
world's  biggest  operator,  maintains  that  small  losses  are 
harmless,  and  states  that  nearly  all  of  his  escapes  are  quite 
small.  Major  Birdwood,  I. M.S.,*  after  a  large  acquaint- 
ance with  vitreous  accident,  says  :  '*  Provided  the  capsule 
(of  the  lens)  is  unruptured  no  evil  effects  whatever  seem 
to  follow  the  escape  of  vitreous  even  when  in  fair  quantity." 
These  opinions,  however,  are  not  shared  by  surgeons  in 
Europe  and  America,  who  are  able  to  follow  up  their  cases. 
And  even  in  India  a  very  different  picture  has  been  drawn — 
from  the  records  of  the  Calcutta  Ophthalmic  Hospital. t 

Among  122  operations  complicated  by  vitreous  expulsion 
there  were  28  failures — presumably  failures  recognized  before 
discharge  from  hospital.  In  9  cases  there  was  atrophy  of  the 
globe.  The  other  failures  were  all  apparently  infective — 10 
by  iritis,  8  by  corneal  sloughing,  and  4  by  panophthalmitis. 
Twenty-two  of  the  122  losses  were  large,  amounting  to  more 
than  a  fourth  of  the  humour.  And  there  were  only  5  failures 
among  these  22  cases.  So  that  it  was  held  that  the  question 
of  the  quantity  lost  had  very  little  influence  upon  the  result. 

I  have  seen  early  shrinking  of  the  globe  rarely,  and 
simple  detachment  of  the  retina  rather  more  frequently, 
either  before  the  patient's  discharge  or  a  few  months  later ; 
but  I  have  no  figures  bearing  upon  the  relative  frequency 
of  these  results.     I  have   thought  that   after   escape   of 

*  Ind.  Med.  Gazette.,  xli  (1906),  201. 

t  L.  M.  Mookerjee,  Trans.  Ind.  Med.  Congress,  1894. 


Vitreous  Accidents  177 

vitreous  in  our  practice  infective  losses  were  more  fre- 
quent. 

For  instance,  in  a  series  of  578  extractions,  there  were 
3  severe  inflammations  leading  to  atrophy.  Two  of  the 
3  cases  occurred  after  loss  of  vitreous.  It  may  be  noted  also 
that  among  9  large  vitreous  losses  reported  by  Smith  ■'  there 
were  3  suppurations.  In  the  matter  of  infection  the  quantity 
lost  can  have  little  bearing.  Probably  Smith's  relative  im- 
munity from  infective  losses  is  attributable  to  his  preliminary 
douching  of  the  conjunctiva  with  i  in  2,000  perchloride. 

*  Ind.  Med.  Gazette.,  xl  (1905),  327. 


12 


CHAPTER   IV 

VARIATIONS    IN   PROCEDURE,   AND 
THEIR   VALUE 

General  preliminary  and  preparatory  details — -Fixation — The  section 
— Simple  extraction — Peripheral  iridectomy — Preliminary  iridec- 
tomy— Other  modes  of  opening  the  capsule — Intraocular  irriga- 
tion— The  open  treatment  of  the  wound — Extraction  of  the  lens 
together  with  its  capsule — Asepsis — Results. 

GENERAL  PRELIMINARY  AND  PREPARATORY 
DETAILS. 

The  Value  of  the  Mouth-Mask  or  Screen. — It  is  well  realized 
nowadays  that  salivary  infection  of  wounds  is  a  danger  seri- 
ously to  be  guarded  against.  But  an  extensive  face  covering 
in  the  form  of  a  veil  is  scarcely  called  for,  since  the  expired 
air  in  breathing  is  harmless.  In  Smith's  Jullundur  work  the 
screen  is  superfluous,  since  neither  he  nor  his  assistant  find 
it  necessary  to  speak  to  the  patient  during  operation  ;  but 
in  ordinary  work  many  of  the  patients  need  repeated  verbal 
directions.  I  have  little  doubt  that  some  of  our  earlier  Bombay 
infections  were  from  this  source.  We  thought,  immediately 
after  the  use  of  the  screens  was  begun,  that  there  was  a 
decided  and  continued  improvement  in  the  average  appearance 
of  the  eyes  after  operation.  We  thought  there  were  fewer 
muddy  pupils  and  irises  seen  requiring  early  treatment. 
Axenfeld*  has  remarked  that  infection  in  eye  operations  is 
almost  exclusively  by  the  pneumococcus,  which  is  rare  in  the 
healthy  conjunctiva,  but  common  in  the  saliva. 

Some  surgeons  lay  stress  upon  the  cleansing  of  their  own 
and  of  their  assistants'  hands,  passing  them  through  the  regula- 
tion brushing  with  soap  and  water,  steeping  in  alcohol  and  in 

*  K/in.  M.f.  A.,  xli  (1903),  2,  474. 
178 


Variations  in  Procedure,  and  their  Value     179 

I  in  1,000  sublimate.  And  they  wear  sterilized  blouses  and 
caps.  De  Schweinitz  sprays  the  nasopharynx  three  times  daily 
with  a  solution  of  permanganate  of  potassium,  i  in  5,000,  as  a 
preparation  for  cataract  extraction. 

The  casual  references  made  in  Chapter  II  to  the 
Cleansing  of  the  Lids  and  surroundings,  and  especially 
of  the  lid  margins,  will  be  regarded  by  many  as  quite 
inadequate.  They  represent  the  general  practice  in 
Bombay  and,  I  believe,  in  India  generally — a  practice 
based  less  upon  conviction  than  upon  an  insufficient 
supply  of  reliable  assistants  and  attendants.  We  frankly 
took  up  the  position  of  making  no  attempt  to  sterilize 
these  surfaces,  or  even  to  clean  them  thoroughly.  We 
recognized  these  surfaces  and  the  eyelashes  as  possibly 
foul,  and  undertook  the  responsibility  of  preventing  con- 
tact between  the  lid  borders  and  lashes  with  the  portions 
of  instruments  which  entered  the  wound.  Particular  care 
in  this  respect  was  exercised  in  making  the  incision,  as 
already  insisted  upon.  But  under  more  favourable  cir- 
cumstances it  would  seem  wise  to  devote  more  attention 
to  the  lid  margins  at  least,  even  admitting  that  complete 
sterilization  cannot  be  attained.  This  is  suggested  by  the 
bare  possibility  that  the  surgeon  may  fail  to  notice 
accidental  contact  of  the  blade  of  the  knife  with  the  lashes 
or  skin  before  the  incision  is  completed.  Considerable 
importance  has  been  laid  also  upon  the  lid  margins  as  one 
of  the  main  sources  of  supply  of  conjunctival  bacteria 
(see  also  the  section  on  *  Asepsis ').  Hence,  thorough 
cleansing  of  the  skin  may  tend  to  lessen  the  risks  of 
secondary  infection  of  the  wound.  At  the  same  time, 
care  must  be  taken  lest  more  harm  than  good  should 
follow   too  energetic  efforts,  by  exciting  inflammation. 

A  common  practice  is  to  cleanse  the  skin  of  the  lids  and 
neighbouring  parts  thoroughly,  either  on  the  preceding 

12 — 2 


i8o  Cataract  Extraction 

day  or  on  the  morning  of  operation,  and  then  to  cover 
the  parts  with  a  compress  moistened  with  antiseptic  fluid, 
until  immediately  before  operation.  At  this  time  a  final 
cleansing  is  practised.  The  initial  washing  is  first  with 
soap  and  hot  water,  then  alcohol,  and  then,  perhaps,  subli- 
mate lotion,  I  in  2,000,  care  being  taken  that  none  of  these 
irritants  reach  the  conjunctiva.  The  compress  is  soaked 
in  I  in  5,000  sublimate,  and  covered  with  guttapercha 
tissue. 

There  is  no  objection  to  covering  up  the  eye  thus  for 
an  hour  or  two  before  operation,  but  applied  as  a  '  test 
dressing'  from  the  preceding  day,  the  compress  continued 
up  to  the  operating  period  is  objectionable.  If  continued 
for  more  than  a  night — the  normal  period  of  closure  in 
sleep — the  immobility  of  the  lids  and  the  warmth  of  the 
dressing  favour  the  growth  of  micro-organisms  in  the  con- 
junctival sac,  and  often  excite  slight  temporary  hyper- 
aemia.  A  few  hours  should  be  given  for  this  to  subside. 
The  prolonged  application  of  weak  perchloride  solution  to 
the  skin  excites  an  acute  discharging  dermatitis  in  a  few 
people.  It  is  urged  against  all  *  test  dressings  '  that  they 
are  apt  to  disturb  the  patient's  sleep,  so  much  needed  the 
night  before  operation. 

Epilation  of  the  cilia,  of  the  whole  of  both  lids,  or  of  the 
upper  lid  only,  has  been  practised  by  a  few  surgeons.  It 
is,  of  course,  a  painful  procedure,  and  may  cause  inflamma- 
tion. On  these  accounts  it  is  more  usual  to  cut  the  lashes 
short.  But  even  this  is  not  required  except  at  the  outer 
portion  of  the  upper  lid  beyond  the  point  where  the  arm 
of  the  speculum  crosses  the  lid  border. 

Here  it  is  necessary  if  the  blade  of  the  knife  is  to  be  guarded 
from  contact  with  the  eyelashes  in  making  the  incision.  But 
there  is  no  difficulty  in  preventing  the  portions  of  instruments 
which   enter  the  wound   from  touching   the  lashes  of  other 


Variations  in  Procedure,  and  their  Value     i8i 

portions  of  the  lids.  If  there  were  any  such  difficulty,  it  could 
be  avoided  by  the  use  of  specula  with  plates  or  bars,  such  as 
Lang's  or  Koster's. 

It  is  recognized  that  the  cilia  and  the  lid  margins  cannot 
be  made  certainly  sterile  by  ordinary  washing  with  soap 
and  lotions.  Benzine  introduced  by  Pflugk*  and  used  by 
Kuhnt,  Mayweg,  and  others,  has  been  recommended  as  a 
cleansing  agent,  f  It  is  non-irritant,  provided  its  action  is 
confined  to  the  skin  surface.  The  swabs  dipped  in  it  are 
squeezed  nearly  dry.  De  Wecker  applied  i  per  cent, 
cyanide  solution  to  the  lashes.  Panas,  True  (Montpellier) 
and  Louis  Dor  (Lyons)  have  used  a  solution  of  biniodide 
of  mercury  in  oil  for  the  lid  margins.  (Panas'  solution 
is  4  in  1,000.)  Hess,  after  washing  with  i  in  2,000  sub- 
limate solution,  applies  sublimate  vaseline,  i  in  1,000. 

The  cleansing  of  the  lid  borders  is  facilitated  by 
cutting  short,  and  still  more  by  pulling  out,  the  lashes. 
Also,  after  operation,  the  lids  cannot  be  glued  together  by 
secretion,  and  the  latter  is  easily  washed  away. 

Expression  of  the  contents  of  Meibomian  glands  as  a  part 
of  the  routine  preparation  of  the  patient  is,  so  far  as  I  am 
aware,  exclusively  a  Bombay  practice.  It  was  forced  upon 
us  by  our  free  use  of  intraocular  irrigation.  Any  operator 
who  separates  the  lids  with  a  speculum,  and  uses  the 
ordinary  irrigator  for  washing  out  cortex,  must  at  times 
have  noticed  the  Meibomian  secretion  floating  upon  the 
fluid  in  the  conjunctival  sac;  and  once  having  seen  the 
material  which  can  be  expressed  from  sluggish  glands,  he 
will  continue  in  a  routine  effort  to  remove  possibly  in- 
fective material.  This  emptying  of  the  glands  appears  to 
be  essential  if  the  lid  borders  are  to  be  maintained  clean 

*  A.f.  A.,  xlv  (1902),  176. 

t  The  benzine  may  act  slightly  as  a  disinfectant,  but  its  main  action 
is  as  a  powerful  solvent  of  fats. 


1 82  Cataract  Extraction 

throughout  a  cataract  operation.  It  seems  especially 
necessary  in  operations  where  the  lower  lid  border  is 
utilized  for  applying  pressure  upon  the  eye  for  the  expul- 
sion of  the  lens  and  of  cortical  remains. 

Some  operators  prefer  to  cover  the  greater  part  of  the 
patient's  face  with  sterilized  gauze,  leaving  only  the  eye 
and  its  immediate  neighbourhood  exposed. 

The  eyebrow,  regarded  as  unsterilizable,  has  been 
shaved  by  a  few  surgeons,  e.g.,  Haab,  Czermak,  lest  bac- 
teria should  be  transferred  from  the  hair  to  the  surgeon's 
hand,  and  this  indirectly  to  the  instruments.  Also  lest 
organisms  should  be  carried  down  by  perspiration  in 
summer  to  the  lid  margins  (Haab). 

General  Anaesthesia. —  C  Mow  form  is  practically  never 
needed  in  cataract  extraction  in  adults.  If  a  patient,  insane  or 
otherwise,  be  so  deficient  in  self-control  that  Czermak's  opera- 
tion by  lower  subconjunctival  section  cannot  be  performed,  he 
will  not  be  a  fit  subject  for  operation,  because  of  the  care 
needed  to  prevent  accident  during  the  healing  period.  And  in 
the  case  of  painful  glaucomatous  eyes  temporary  measures  can 
be  employed  to  reduce  tension  till  the  eyes  are  fit  for  opera- 
tion. The  only  occasions  on  which  one  might  be  compelled  to 
use  general  anaesthesia,  would  be  when  a  patient  became 
uncontrollable  during  operation.  But  of  late  years  I  have  not 
met  with  such. 

Apart  from  the  question  of  risk  to  life,  chloroform  is 
objectionable,  because  of  the  danger  of  prolapse  of  iris  or  loss 
of  vitreous  occurring  afterwards  from  vomiting.  More  time 
is  taken  up  by  the  operation,  and  unless  the  patient  be  kept 
completely  under  the  influence  of  the  anaesthetic,  inconvenience 
is  occasioned  by  the  eyeball  rolling  upwards. 

In  operating  upon  children  by  linear  extraction  chloroform 
may  be  needed,  but  the  quantity  given  may  be  much  reduced 
if  cocain  be  instilled  into  the  eye,  as  usual,  also. 

General  anaesthesia  by  subcutaneous  injection  of  scopo- 
lamine and  morphine  has  been  recommended  by  Suker*  and 

*  Medicine^  January,  1906. 


Variations  in  Procedure,  and  their  Value     183 

Segelken.*  One-fiftieth  of  a  grain  of  scopolamine  hydro- 
bromate  (Merck)  and  half  a  grain  of  morphine  sulphate  are 
dissolved  in  three  drachms  of  distilled  water.  One  Pravaz 
syringe  full  of  this  solution  is  injected  three  hours  before  opera- 
tion, and  a  second  similar  dose  given  one  and  a  half  hour 
later.  A  few  drops  of  cocain  solution  are  instilled  before 
operating.  Although  the  patient  is  apparently  comatose,  he 
can  turn  the  eye  in  any  direction  when  asked  to  do  so.  The 
solution  '  Skopomorphin '  can  be  obtained  sterilized  in  tubes 
from  J.  D.  Riedel,  Berlin. 

The  Cleansing  of  the  Conjunctiva. 

The  value  of  perchloride  irrigation  of  the  conjunctiva 
before  operation,  and  its  mode  of  action,  are  discussed  at 
the  end  of  this  chapter,  under  '  Asepsis.'  The  fairly  general 
affection  evinced  by  eye  surgeons  for  sublimate  lotion 
is  based  upon  wide  clinical  experience.  This  solution  has 
been  much  more  extensively  tested  than  any  other  antiseptic 
fluid,  in  spite  of  the  irritation  set  up  by  it.  And  the 
explanation  is  that  its  usefulness  depends  mainly  upon  its 
action  on  the  conjunctival  tissues.  Laboratory  research 
showed  years  ago  that  there  was  little  prospect  of  success 
in  the  search  for  an  effective  but  unirritating  conjunctival 
antiseptic.  And  according  to  present  evidence,  it  would 
be  a  mistake  to  attempt  to  replace  the  perchloride  by 
cyanide  of  mercury  solution,  or  by  other  antiseptic  fluids, 
which,  with  a  given  bactericidal  power,  produce  less 
irritation. 

The  drawback  to  the  use  of  the  perchloride  is  the 
inflammatory  reaction  set  up  by  it.  But  our  Bombay 
experience  shows  how,  by  adjustment  to  individual  needs, 
the  reaction  can  be  kept  within  bounds.  Any  unusual 
degree  of  conjunctivitis  excited  is  in  itself  but  a  slight 
temporary  inconvenience,  of  no  real  consequence  whatever. 

*  /C/t'n.  Monads./.  A.,  Juli,  1907. 


184  Cataract  Extraction 

It  is  gratifying  to  the  operator  that  the  eye  should  remain 
free  from  noticeable  reaction,  but  it  is  necessary  to 
distinguish  between  personal  gratification  and  actual 
benefit  to  the  patient.  It  is,  of  course,  better  to  irritate  a 
hundred  eyes  than  to  lose  one  by  suppuration.  It  might 
be  anticipated  that  this  traumatic  inflammation  might 
occasionally  tend  to  favour  secondary  infection  of  imper- 
fectly healed  wounds.  For  such  reactions  are  known 
to  encourage  the  multiplication  of  pathogenic  cocci  in  the 
conjunctival  sac.  But  no  clinical  evidence  is  forthcoming 
of  wounds  being  thus  influenced.  Excessive  reaction, 
however,  may  do  harm  by  simple  spread  to  the  deeper 
tissues  of  the  eye.  Where  much  lid  swelling  is  occasioned 
by  the  conjunctival  application,  it  is  reasonable  to  suppose 
that  some  slight  injection  of  iris  and  ciliary  body  may  be 
set  up  from  the  surface  irritation,  such  as  may  be  observed 
commonly  with  any  slight  corneal  lesion.  And  this, 
acting  together  with  other  causes  of  iritic  reaction,  may 
assist  in  the  development  of  iritis.  Practically  the  extent 
of  this  drawback,  as  seen  clinically,  consists  in  the  need 
for  more  atropin  after  operation  than  would  otherwise  be 
used.  Another  point  frequently  scored  against  perchloride 
is  that  by  injuring  the  tissues  it  renders  them  less  able  to 
cope  with  any  pyogenic  organisms.  But  since  the  lotion 
does  not  gain  access  to  the  wound  and  is  only  applied  to 
the  conjunctiva  beforehand,  the  objection  does  not  apply. 
Where  no  pathogenic  organisms  are  present  even  simple 
mechanical  cleansing,  if  at  all  vigorously  carried  out,  may 
be  objected  to  as  causing  a  slight  unnecessary  reaction. 

The  ideal  procedure  would  be  the  determination  of  the 
presence  or  absence  of  pathogenic  organisms,  and  such 
preliminary  treatment  of  the  conjunctiva  as  proved 
necessary  to  remove  these  inhabitants.  Some  attempt 
has  been  made  in  this  direction,  e.g.,  by  Freeland  Fergus. 


Variations  in  Procedure,  and  their  Value     185 

Simple  cultures  upon  Loffler's  serum,  supplemented  oc- 
casionally by  subcultures,  supply  fairly  definite  information. 
One  would  prefer  not  to  operate,  as  we  found  we  were  doing 
in  Bombay,  in  the  presence  of  pneumococci  or  streptococci, 
orange  or  citron  staphylococci,  or  diplo-bacilli,  or  even  of 
numerous  white  staphylococci.  Freeland  Fergus*  is  of 
opinion  that  the  Staph,  alhns  does  not  cause  suppurations, 
or  even  iritis  or  irido-cyclitis,  but  if  present  in  considerable 
quantity,  almost  invariably  gives  rise  to  conjunctivitis  after 
operation. 

Had  there  been  means  and  opportunity  in  Bombay,  however, 
for  carrying  out  bacteriological  examinations  at  a  sufficient 
interval  before  operating,  the  knowledge  obtained  would  have 
been  an  embarrassment,  and  would  have  lessened  the  useful- 
ness of  the  hospital.  We  would  have  feared  to  operate  in 
many  cases  even  with  the  help  of  perchloride,  and  would  have 
kept  patients  attending  for  outdoor  treatment  until  many  of 
them  would  have  fallen  into  the  hands  of  the  couching  quacks. 

Bacteriological  examination  would  be  appealed  to  more 
commonly  did  surgeons  feel  perfect  confidence  in  the  result. 
One  fears  to  place  implicit  trust  in  a  negative  result,  which 
may  possibly,  by  some  rare  chance,  be  due  to  faulty  technique. 
There  is  also  the  feeling  that  a  few  dangerous  microbes  may 
escape  detection,  lying  in  folds  or  recesses.  Probably,  however, 
such  scattered  organisms  are  of  little  account,  for  it  is  recog- 
nized that  a  certain  dosage  is  required  for  the  effective  lodgment 
of  pyogenic  organisms  in  a  wound.  However  this  may  be,  it 
was  curious  that  the  one  complication,  presumably  infective, 
which  occurred  among  our  fifty  cases  bacteriologically  ex- 
amined (see  later)  was  in  an  eye  in  which  the  test  gave  no 
warning  of  danger,  f 

*  Brit.  Med.Journ.,  March,  1905. 

t  It  was  one  of  our  rare  cases  of  occlusion  of  the  pupil  from  iritis. 
But  the  iritis  was  not  very  severe  ;  there  was  neither  much  injection 
of  the  eye  nor  much  exudation.  The  closure  of  the  pupil  came  as  a 
surprise,  and  was  apparently  largely  due  to  the  treatment  being  at 
first  very  mild.  From  the  conjunctiva  after  perchloride  irrigation 
only  one  colony  of  white  staphylococci  was  grown,  while  the  tube 
inoculated  before  irrigation  furnished  eight  colonies  of  white  staphylo- 
cocci and  two  small  moist  pits  suggestive  of  early  diplo-bacillary 
colonies,  which,  however,  did  not  develop. 


1 86  Cataract  Extraction 

Separation  and  Control  of  the  Lids. 

The  advantages  of  the  stop-speculum  are  somewhat 
more  evident  in  dealing  with  deeply  set  eyes  than  with 
others,  for  the  risk  of  vitreous  accident  from  contraction  of 
the  orbicularis  is  least  in  these  cases,  and  wide  separation 
of  the  lids  is  most  needed.  The  danger  of  vitreous 
expulsion,  in  so  far  as  it  is  due  to  the  speculum  properly 
elevated,  is  explained  by  the  fact  that  the  peripheral  fibres 
of  the  orbicularis  muscle  are  alone  able  to  press  upon  the 
eyeball.  The  elevation  of  the  tarsal  portions  of  the  lids 
leaves  the  front  of  the  globe  unsupported,  and  the  corneal 
flap  can  be  thus  forced  forwards.  Hence  it  has  become 
customary  to  insist  upon  some  provision  for  very  rapid 
removal  as  one  of  the  essentials  in  the  design  of  a 
satisfactory  speculum.  There  is  no  such  provision  in  the 
screw  adjustment,  which  is  the  only  stop  mechanism  with 
which  I  have  had  extensive  experience ;  and  I  have  not 
found  the  want  of  it  noticeably  embarrassing.  When 
harm  is  done  by  spasm  of  the  orbicularis,  it  is  nearly 
always  at  the  first  moment  of  the  contraction.  The 
muscle  is  commonly  relaxed  again  at  a  sharp  word  of 
command  from  the  surgeon,  and  the  instrument  is  readily 
withdrawn  before  further  contraction  can  take  place. 
Automatic  removal,  brought  about  by  the  actual  con- 
traction of  the  lids,  as  in  Miiller's  speculum,  is  the  only 
mode  of  removal  rapid  enough  to  guard  the  vitreous 
effectually.  And  the  sudden  closure  of  the  lids  permitted 
may  do  harm  should  any  instrument  be  in  the  wound 
at  the  time  or  should  the  iris  be  in  the  grip  of  the  iris 
forceps,  or  should  the  wound  be  gaping  widely,  with 
the  lens  lying  in  it.  Again,  violent  contraction  of  the 
orbicularis  is  frequently  foreshadowed  by  preliminary 
twitches    or    blinkings,   which    serve    as    a   warning    for 


Variations  in  Procedure,  and  their  Value     187 

removal  of  the  speculum,  and  substitution  of  other  means 
for  separating  the  lids.  Our  figures  (p.  i6g)  show  how 
infrequent  vitreous  accident  from  spasm  of  the  lids  may 
be,  in  working  with  the  ordinary  screw  speculum  under 
the  general  precautions  indicated  in  Chapter  III. 

With  Desmarres'  retractor  in  the  hands  of  an  experi- 
enced assistant,  powerful  spasm  of  the  orbicularis  may  be 
effectually  resisted  without  endangering  the  vitreous, 
except,  perhaps,  in  the  case  of  unusually  prominent  eyes. 
Yet  it  is  extraordinary  sometimes  how  the  muscle  is  able 
to  exert  pressure  upon  the  globe,  with  the  retractor  firmly 
pressed  against  the  roof  of  the  orbit.  With  the  stem  bent 
as  shown  in  Fig.  41  the  instrument  can  be  used  more 
effectively  to  control  the  action  of  the  orbicularis  muscle, 
but  it  is  not  so  easily  withdrawn  when  the  muscle  is 
contracting. 

In  Chapter  II  separation  of  the  lids  by  the  assistant's 
fingers  is  considered  only  as  a  substitute  for  the  use  of  the 
speculum  after  the  section  has  been  completed.  But  a  few 
surgeons  employ  it  in  making  the  incision,  e.g.,  Sir  Ander- 
son Critchett.  When  working  without  an  assistant,  this 
operator  elevates  the  upper  lid  with  the  ring  finger 
of  the  hand  holding  the  fixation  forceps.*  Trousseauf 
(Paris)  employs  his  own  finger  and  thumb  for  separation 
of  the  lids  and  for  fixation  of  the  eye.  The  chief 
objection  to  control  of  the  lids  by  the  fingers  alone,  apart 
from  its  comparative  ineffectiveness,  is  an  inadequate 
protection  against  infective  risks. 

*  The  Ophthalmoscope,  iv  (1906),  112.  Critchett  says:  "The 
sensitive  natural  speculum  possesses  this  great  advantage,  that  it  can 
recognize  the  beginning  of  a  spasmodic  effort  on  the  part  of  the 
patient,  and  can  at  once  give  the  necessary  relaxation,  and  as  the 
section  is  nearing  its  completion,  the  gradual  withdrawal  of  the  finger 
allows  the  lids  to  close  gently  and  without  effort." 

t  La  Clinique  Opkfal.,  November  25,  1905. 


1 88  Cataract  Extraction 

When  the  lids  have  to  be  released  on  powerful  spasm 
occurring,  the  edge  of  the  corneal  flap,  possibly  with  the  con- 
junctival flap  lying  over  it,  deep  surface  foremost,  sweeps 
upwards  in  contact  with  the  conjunctiva  of  the  upper  lid.  And 
should  closure  of  the  lids  occur  with  the  lens  half  out  of  the 
wound,  the  corneal  flap  may  be  carried  down  by  the  bacterio- 
logically  unclean  border  of  the  upper  lid,  and  thus  possibly 
the  zonule  ruptured,  vitreous  lost,  and  the  interior  of  the  eye 
widely  exposed  to  any  bacteria  present  in  the  conjunctival 
sac.  Should  this  accident  occur,  the  lower  lid  must  be  firmly 
depressed  by  the  assistant,  while  the  upper  lid  is  elevated  by 
pulling  on  the  lashes,  or,  if  necessary,  by  the  insertion  of 
Desmarres'  elevator,  and  the  flap  replaced  by  the  curette. 

Angelucci  raises  the  upper  lid  by  means  of  the  fixation 
forceps  gripping  the  tendon  of  the  superior  rectus. 


FIXATION. 

Some  operators  who  complete  as  much  as  possible  of  the 
section  in  the  first  inward  stroke  of  the  knife,  fix  the  globe 
with  forceps  at  the  inner  side  of  the  cornea,  to  resist  the  thrust 
of  the  knife.  The  forceps  applied  here  may  be  of  some  slight 
service  in  defining  the  site  of  the  counter-puncture.  In  our 
work  with  a  gentler  use  of  the  knife,  fixation  is  more  needed 
below  to  resist  the  upward  pull  in  the  sawing  movements  of  the 
blade. 

Ang-elucci's  Method  of  Fixation. — Fixation  of  the  globe 
by  gripping  the  insertion  of  a  rectus  muscle  (the  internal)  with 
forceps  through  the  conjunctiva  was  practised  by  Macnamara. 
Angelucci  *  is  warmly  supported  by  Gutmann  f  in  claiming 
special  benefits  derived  from  his  method  of  fixing  the  eye 
by  grasping  the  tendon  of  the  superior  rectus  muscle.  He 
performs  simple  extraction  through  an  upper  section  compris- 
ing little  more  than  one-third  of  the  corneal  circumference,  and 
incises  the  lens  capsule  with  the  point  of  the  knife  as  it  passes 
across  the  chamber.  The  fixation  forceps  serve  not  only  to 
fix  the  globe,  but  also  to  elevate  the  upper  lid.     They  should 

*  Arch,  di  OftaL,  vi  (1899),  260. 

t  Bericht  der  xxx  Versamm.  der  ophth.  Ges.  in  Heidelberg^  1902, 
S.  239. 


Variations  in  Procedure,  and  their  Value     189 

have  ends  3  millimetres  broad,  and  teeth  not  very  pointed. 
Angelucci  dispenses  with  an  assistant,  and  does  not  depress 
the  lower  lid.  The  upper  lid  is  first  well  elevated  by  the 
thumb  of  the  right  hand,  while  the  forceps,  held  in  the  left 
hand,  and  pressing  deeply,  seize  the  conjunctiva  and  the  under- 
lying tendon  4  to  5  millimetres  from  the  corneal  margin.  This 
hold  is  maintained  while  the  various  steps  of  the  operation  are 
performed  with  the  right  hand. 

It  is  stated  that  the  fixation  so  close  to  the  section  entirely 
immobilizes  the  eye,  and  the  making  of  the  section  is  conse- 
quently very  easy.  The  forceps  serve  for  counter-pressure  in 
expelling  the  lens  in  the  ordinary  way  with  Daviel's  spoon. 
The  pressure  required  is  only  light,  and  therefore  there  is  little 
risk  of  vitreous  accident,  and  rarely  any  injury  to  the  iris  or 
any  prolapse.  The  return  of  the  iris  within  the  chamber  is 
facilitated  by  the  forward  pull  of  the  forceps  on  the  scleral 
margin  of  the  wound.  In  senile  enophthalmos  and  in  ble- 
pharophimosis  the  forward  pull  of  the  forceps  is  an  advantage. 
It  would  seem  that  the  hold  on  the  muscle  must  be  frequently 
painful,  and  therefore  likely  to  excite  spasm  of  the  lids. 


THE  SECTION. 

Variation  in  the  style  of  cutting  is  optional,  thus : — 
Many  surgeons  attempt  always  to  complete  the  section 
in  one  double  movement  of  the  knife,  in  and  out.  This 
may  frequently  be  accomplished  with  a  fairly  broad  and 
sharp  knife.  Czermak  used  a  blade  3  to  3*5  millimetres 
broad.  Critchett  and  Kuhnt  have  employed  the  knives 
already  described. 

It  is  by  no  means  always  possible,  however,  to  finish 
the  section  thus  simply  and  rapidly  without  using  more 
force  than  one  may  consider  advisable.  This  is  particu- 
larly so  whenever  a  long  sweep'^  of  the  knife  is  impracti- 

*  A  slightly  longer  movement  of  the  blade  is  practicable  if  the  eye 
be  turned  a  little  outward,  or  if  the  same  effect  be  got  by  keeping  the 
eye  fixed  and  turning  the  head  a  little  to  the  other  side. 


190  Cataract  Extraction 

cable  —  in    sunken    eyes,    therefore,    and    in    those   with 
contracted  palpebral  aperture. 

When  it  can  be  effected  easily,  the  incision  by  this  one 
to-and-fro  stroke  presents  two  claims  upon  our  considera- 
tion :  (i)  It  makes  a  wound  with  perfectly  smooth  level 
surfaces.  And  such  wounds  are  much  more  likely  to  unite 
rapidly  and  firmly  than  others  somewhat  jagged  and 
uneven.  This  is  important  in  operations  where  the 
conjunctival  flap  is  dispensed  with,  or  where  only  a  small 
apical  flap  is  made.  And  more  especially  so  if  at  the 
same  time  no  iridectomy  is  made,  since  early  union  is 
relied  upon  to  prevent  prolapse  of  the  iris.  (2)  An 
advantage  much  more  appreciated  in  simple  than  in 
combined  extraction  is  that  some  aqueous  is  retained  in 
the  chamber  during  the  greater  part  of  the  cutting. 
Thus  injury  to  the  iris  by  the  knife  is  prevented,  and  this 
is  an  additional  safeguard  against  subsequent  prolapse. 

There  are  two  drawbacks  to  this  mode  of  cutting : 
(i)  The  higher  degree  of  force  that  one  is  tempted  to 
exert  to  complete  the  incision  with  a  knife  which  is 
beginning  to  lose  its  edge  must  endanger  a  weak  zonule. 
And  this  ligament  may  be  further  endangered  by  any 
slight  twist  of  the  broad  blade  which  may  be  required  in 
following  the  edge  of  the  cornea  upwards,  causing  the 
back  of  the  blade  to  press  upon  the  lens  and  iris.  (2)  This 
mode  of  cutting  does  not  afford  facilities  for  shaping  any 
conjunctival  covering  except  at  the  summit  of  the  wound, 
for  so  much  of  the  incision  is  accomplished  in  the  mere 
puncture  and  counter-puncture  by  a  very  broad  Graefe's 
knife.  And  the  fashioning  of  anything  approaching  a 
complete  conjunctival  flap  depends  so  much  upon  the 
slight  alterations  in  the  plane  of  the  blade  which  are 
practicable  during  sawing  movements,  that  it  is  found  that 
the  narrower  the  blade  the  more  nearly  can  one  succeed 


Variations  in  Procedure,  and  their  Value     191 

in  the  difficult  outlining  of  any  particular  design  of  con- 
junctival appendage. 

On  the  other  hand,  the  narrower  the  blade  the  more 
often  will  the  iris  be  cut  or  scraped  by  it,  owing  to  escape 
of  aqueous  before  the  edge  of  the  knife  has  passed  well  up 
in  front  of  the  iris.  This  in  spite  of  the  fact  that  slight 
alterations  in  the  plane  of  the  narrow  blade  may  often  be 
made  without  appreciable  loss  of  aqueous.* 

Thus,  in  our  work,  wanting  always  a  moderately 
complete  conjunctival  covering,  and,  though  frequently 
attempting  the  simple  operation,  more  frequently  ending 
with  the  combined,  we  found  the  blade  of  medium  width, 
2  millimetres  exactly,  most  satisfactory.  It  was  not  too 
broad  for  the  cutting  of  a  satisfactory  conjunctival  flap, 
and  was  yet  broad  enough  to  obviate  frequent  injury  to 
the  iris. 

A  narrow  blade  is  more  easily  guided  across  a  very 
shallow  anterior  chamber,  pressing  less  against  the  lens 
and  iris. 

If  one  attempt  to  accomplish  the  whole  or  greater 
portion  of  the  section  in  one  movement  of  a  medium 
or  rather  narrow  blade,  the  push  of  the  knife  is  somewhat 
apt  to  force  out  aqueous  and  iris  through  the  wound  at 
the  inner  side  below  the  knife. 

The  Conjunctival  Flap  serves  several  purposes : 

I.  Its  chief  function  is  as  a  protection  against  infection 
of  the  eye.  Serving  as  a  covering  for  the  wound,  it  must 
bar  the  entry  of  micro-organisms  from  the  conjunctival 
sac  after  the  operation.     And  for  this  purpose,  the  more 

*  The  slightest  twist  of  a  broad  blade  at  once  empties  the  chamber 
of  aqueous.  In  our  earlier  practice  we  found  the  iris  more  often 
injured  by  broad-bladed  knives.  But  this  was  due  to  want  of  care  in 
placing  the  blade  correctly  before  beginning  the  incision.  One  of  the 
chief  objections  to  the  old  broad  Beer's  knife  was  the  difficulty  in 
altering  its  plane  during  the  making  of  the  section. 


192  Cataract  Extraction 

complete  the  covering,  presumably  the  more  effective 
should  it  be,  especially  in  eyes  where  vitreous  tends  to 
press  the  corneal  flap  forward.  It  is  doubtful,  however, 
whether  in  ordinary  cases  a  protective  covering  is  in  any 
degree  necessary  or  advisable,  except  about  the  middle  of 
the  wound — at  the  summit  of  the  arch.  It  is  here  that 
any  gaping  of  the  wound  tends  to  be  widest.*  And  it  is 
here,  also,  that  micro-organisms  are  most  likely  to  be 
worked  into  the  wound  from  the  overlying  palpebral  con- 
junctiva by  movements  of  the  eyeball,  since  uncontrolled 
movements  after  operation,  just  as  during  operation,  are 
presumably  mostly  in  the  vertical  direction.  And  probably 
the  making  of  even  a  small  localized  flap  may  be  considered 
indirectly  to  guard  against  secondary  infection  to  some 
extent  by  ensuring  that  a  portion  of  the  incision  traverses 
vascular  scleral  tissue. 

It  is  not  unreasonable  to  suppose  further  that  the 
protective  influence,  as  regards  infection,  which  we 
attribute  to  the  conjunctival  flap,  is  exerted  partly  during 
the  actual  operation. 

The  mere  covering  then  appears  to  be  of  little  value,  unless, 
possibly,  to  screen  the  eye  from  the  operator's  saliva  in  speaking. 
But  the  cutting  of  the  flap  provides  a  strip  of  raw  sterile 
surface,  enlarged  by  retraction  of  the  elastic  membrane,  over 
which  instruments  pass  in  entering  the  eye.  Thus  the  instru- 
ments are  not  likely  to  carry  in  conjunctival  organisms.  If 
the  conjunctival  flap  be  left  in  place,  instruments  inserted 
beneath  it  have  to  pass  between  two  active  raw  surfaces,  likely 
to  rub  off  loose  bacteria  from  the  instruments,  and  well  able  to 
dispose  of  them  subsequently. 

2.  The  very  rapid  adhesion  of  a  conjunctival  flap  to 
the  underlying  tissue  must  undoubtedly  tend  to  prevent 

*  It  is  understood  that  reopening  of  the  indsion  towards  either  end 
from  prolapse  of  iris  is  at  once  remedied  by  excision  of  the  prolapse. 


Variations  in  Procedure,  and  their  Value     193 

prolapse  of  iris.  But  this  statement  needs  qualifying 
greatly.  Since  a  cataract  incision  largely  covered  by 
conjunctival  flap  must  be  at  least  partly  sclero-corneal, 
this  peripheral  situation  of  the  section,  as  compared  with 
one  at  or  in  front  of  the  limbus,  is  calculated  to  more  than 
counterbalance  any  benefit  derivable  from  the  conjunctival 
covering.  For  another  reason,  any  value  attributable  to 
the  conjunctival  appendage  as  a  preventive  of  prolapse  is 
restricted  mainly  to  the  smaller  conjunctival  flaps  (see 
below). 

3.  The  use  of  the  flap  makes  the  complication,  delayed 
union  of  the  wound,  as  shown  by  non-retention  of  aqueous, 
a  rare  one  and  almost  a  negligible  one.  Should  the 
complication  occur,  it  will  not  persist  for  long,  and  will 
not  require  treatment,  and  there  is  no  fear  of  down-growth 
of  surface  epithelium  into  the  anterior  chamber,  with 
its  subsequent  liability  to  induce  probably  incurable 
glaucoma. 

4.  We  attributed  our  almost  complete  exemption  from 
secondary  glaucoma  in  Bombay  cataract  work  mainly  to 
our  very  general  use  of  an  extensive  conjunctival  flap.  A 
permanently  filtering  cicatrix — rendering  rise  of  tension 
practically  impossible  —  appears  to  be  the  constant  and 
inevitable  result  of  any  recognizable  separation  of  the 
sclero-corneal  incision  under  the  conjunctival  covering. 

5.  A  quite  minor  advantage  of  the  conjunctival  ap- 
pendage is  in  the  use  that  may  be  made  of  it  to  draw  open 
the  wound  during  operation,  for  the  iridectomy  and  in  the 
expulsion  of  the  lens. 

Drawbacks. — (i)  During  operation  it  may  be  a  little  in 
the  way  when  the  iris  is  being  cut,  but  the  chief  trouble 
from  it  then  is  (2)  the  haemorrhage  into  the  anterior 
chamber,  which  is  to  be  expected  more  or  less  with  any 
extensive   flap   unless   adrenalin   solution    has    been    in- 

13 


194  Cataract  Extraction 

stilled.  This  blood  is  not  only  a  nuisance  at  the  time, 
interfering  with  the  capsulotomy  and  with  the  removal  of 
cortex,  but  also  afterwards.  A  little  of  it  may  become 
organized,  causing  permanent  after-cataract  and  synechise. 
The  bleeding  is  to  be  more  carefully  guarded  against  in 
intracapsular  extraction,  since  here  the  blood  cannot 
well  be  washed  away.  Still,  these  are  not  very  serious 
matters.  Also  may  be  mentioned  as  a  slight  drawback 
(3)  the  difficulty  experienced  in  outlining  the  flap  exactly 
as  one  wishes.  (4)  After  operation  the  separation  of  the 
deep  wound,  which  takes  place  under  a  too  complete 
conjunctival  covering,  presents  very  decided  disadvantages 
to  set  against  the  advantage  already  claimed  (namely,  the 
value  of  this  separation  as  a  safeguard  against  secondary 
glaucoma).  They  are  (a)  the  permanent  astigmatism 
attributable  to  it,  occasionally  considerable  in  amount ; 
(b)  some  slight  fear  of  accident  to  such  of  these  eyes  as 
pass  through  a  prolonged  low-tension  period ;  and  (c)  the 
very  occasional  late,  gradual  incarceration  or  prolapse  of 
iris  in  a  wound  gaping  under  the  conjunctival  flap,  seen 
by  us  especially  after  combined  extraction.  This  occur- 
rence is,  however,  too  infrequent,  even  with  a  very  extensive 
conjunctival  flap,  to  greatly  qualify  the  statement  above 
made  on  the  use  of  the  flap  as  a  preventive  of  prolapse. 
Moreover,  this  late  prolapse,  always  small,  is  removable 
without  any  particular  risk  or  difficulty.  And  all  of  these 
drawbacks  apply  only  to  a  covering  left  considerably 
larger  than  usually  necessary.  They  can  be  avoided  by 
trimming  the  flap,  except  where  vitreous  presenting  in 
the  wound  renders  this  inadvisable.  (5)  Very  rarely  the 
flap  fails  in  its  purpose  through  becoming  folded  down 
over  the  cornea. 

The  question  of  the  Size  of  the  wound  is  not  one  of 
importance   nowadays.      With   the   application    of    such 


Variations  in  Procedure^  and  their  Value     195 

antiseptic  and  aseptic  precautions  as  are  now  in  vogue,  it 
is  found  that  with  a  flap  not  exceeding  a  semicircle  the 
tissues  are  sufficiently  well  nourished  to  guard  against 
the  possibilities  of  sloughing  or  suppuration  of  the  flap. 
The  form  of  the  section  may  also  be  taken  as  finally 
settled  for  routine  extraction. 

The  most  suitable  Site  of  the  incision  with  relation  to 
the  corneal  circumference,  however,  is  still  not  finally 
settled. 

The  reduced  liability  to  suppuration  of  sclero-corneal 
wounds  as  compared  with  purely  corneal  ones  was  seen 
in  the  improved  results  obtained  in  pre-antiseptic  days 
with  Jacobson's  and  von  Graefe's  incisions.  The  super- 
ficial vascular,  scleral  and  conjunctival  tissues  serve  to 
protect  the  underlying  cornea  from  bacterial  invasion. 
The  resistance  of  the  limbus  and  of  the  cornea  imme- 
diately underlying  it  is  also  well  recognized  in  destructive 
suppurative  processes.  (Though  the  protected  marginal 
zone  of  cornea  generally  includes  a  rim  of  tissue  within 
the  normal  limbus,  this  appears  to  be  due  to  rapid  in- 
growth of  the  limbus  blood-vessels,  rather  than  to  an 
influence  exerted  beyond  the  terminations  of  the  blood- 
vessels. The  rim  of  cornea  saved  is  found  covered  at  the 
time  with  new  vessels.  Our  knowledge  of  acute  suppura- 
tions of  the  cornea,  therefore,  does  not  warrant  us  in 
expecting  the  same  protection  to  be  afforded  by  the 
limbus  covering,  in  the  case  of  a  section  at  the  edge  of  the 
clear  cornea,  as  when  both  lips  of  the  incision  lie  a  little 
further  back.)  The  comparative  safety  of  sclero-corneal 
wounds  is  probably  explained,  not  only  by  their  vascu- 
larity— which  enables  them  to  dispose  of  bacteria  lying  in 
them  and  also  leads  to  quicker  healing — but  also  by  the 
usual  absence  of  the  superficial  groove  which  is  formed  by 
retraction   of    Bowman's    membrane    in    purely  corneal 

13—2 


196  Cataract  Extraction 

sections.     More  important  than  this  is  the  protection  of 
the  conjunctival  flap. 

A  minor  advantage  of  a  peripheral  puncture  and 
counter-puncture  is  the  lengthening  of  the  base  line  of 
the  flap,  enabling  the  lens  to  escape  more  easily.  But 
this  is  more  than  counterbalanced  by  an  increased 
liability  to  cutting  and  scraping  of  the  iris  by  the  knife, 
and  by  frequent  trouble  with  haemorrhage  during  opera- 
tion. (The  tendency  to  bleeding,  however,  is  a  very 
minor  drawback,  since  it  can  be  prevented  by  the  use  of 
adrenalin  beforehand.)  A  more  definite  disadvantage  is 
the  increased  risk  of  subsequent  prolapse. 

By  a  section  placed  more  anteriorly,  in  clear  cornea, 
trouble  with  the  iris  is  more  commonly  avoidable — both 
accidental  section  and  prolapse.  Hence  the  advantage  of 
such  a  section  in  the  simple  operation.  And  there  can  be 
no  trouble  from  bleeding.  But  few  surgeons  care  to  place 
any  portion  of  the  incision  definitely  within  the  boundary 
of  clear  cornea,  on  account  of  the  infective  risks.  Also 
the  post-operative  astigmatism  tends  to  be  greater  the 
nearer  the  incision  to  the  centre  of  the  cornea  (though 
the  average  amount  from  a  purely  corneal  section  is 
probably  less  than  that  from  a  sclero-corneal  section 
gaping  under  a  large  conjunctival  flap).  And  any  ad- 
hesion of  iris  or  capsule  to  the  line  of  the  wound  appears 
the  more  likely  to  lead  to  secondary  glaucoma  the  further 
forward  the  incision  is  made. 

Smith  of  Jullundur  appears  to  derive  some  advantage 
from  an  upper  corneal  section  ending  well  below  the 
corneal  circumference,  in  that  he  is  able  to  deliver  the 
lens  more  easily  without  requiring  the  patient  to  look 
down.      » 

The  fairly  general  selection  of  the  site  at  the  margin 
of  clear  cornea  has  been  in   the   hope  of  retaining  the 


Variations  in  Procedure,  and  their  Value     197 

benefits  of  the  purely  corneal  section,  and  at  the  same 
time  securing  some,  if  not  all,  of  the  safety  pertaining  to 
more  peripheral  incisions.  This  question  of  safety  from 
infective  risks  overshadows  all  others.  If  it  can  be  shown 
that  infective  complications  may  be  as  completely  ex- 
cluded as  by  the  sclero-corneal  incision,  the  placing  of  the 
puncture  and  counter-puncture  in  the  boundary  of  clear 
cornea  is  more  than  justified.  For  it  is  still  quite  easy  to 
outline  a  conjunctival  flap  above.  In  some  eyes  this 
necessitates  turning  the  edge  of  the  knife  somewhat  back- 
wards in  completing  the  section,  but  in  other  eyes  (see 
p.  64)  the  knife  in  cutting  up  parallel  to  the  iris  becomes 
placed  behind  the  conjunctiva  above.  But  it  has  yet  to 
be  shown  that  infection  can  be  certainly  excluded  with 
such  a  section.  In  Bombay  we  have  been  able  to  exclude 
suppurations  entirely  with  our  sclero-corneal  section,  both 
those  beginning  in  the  cornea  and  those  beginning  as 
severe  irido-cyclitis.  It  is  to  be  noted  that  we  did  not 
entirely  escape  irido-cyclitis  ending  in  sympathetic  loss  of 
the  fellow  eye.  We  had  reason  to  think,  however,  that 
finally  this  possibility  had  been  practically  excluded.  And 
there  is  no, doubt  the  cases  observed  were  due  largely  to 
neglect  after  operation.  The  question  is  of  importance 
here,  because  in  old  days  it  was  found  that  the  reduction 
of  corneal  wound  suppurations  by  the  adoption  of 
von  Graefe's  peripheral  linear  section  was  counter- 
balanced by  an  increase  of  losses  from  deep  infective 
inflammations  ending  sometimes  in  sympathetic  oph- 
thalmia. But  there  is  little  doubt  that  these  losses  were 
mainly,  if  not  entirely,  attributable  to  the  frequent  incar- 
cerations of  iris  in  the  very  peripheral  wounds. 

The  Downward  Section  was  practically  the  only  one 
available    for   the   early   operations   without   anaesthesia. 


198  Cataract  Extraction 

Neither  speculum  nor  fixation  forceps  was  needed,  and  the 
whole  operation  was  less  painful  and  less  trying  to  the 
patient.  The  lens  and  cortical  remains  were  compara- 
tively easily  expressed,  and  the  manipulation  of  the  various 
instruments  could  be  carried  out  conveniently  without 
much  exposure  of  the  eyeball. 

The  ordinary  lower  section,  however,  has  serious  draw- 
backs. The  risk  of  infection  is  increased  by  the  danger 
of  accidental  contact  of  the  wound  with  the  lower  lid 
margin  in  movements  of  the  eye  during  operation,  and  by 
the  position  of  the  wound  opposite  the  lid  space  after- 
wards. According  to  our  Bombay  experience  there  is  a 
greater  tendency  to  loss  of  vitreous,  from  two  causes.  The 
wound  in  this  situation  is  (1)  more  easily  forced  open  by 
contraction  of  the  lids,  and  (2)  also  liable  to  be  pulled 
open  by  the  drag  of  the  lower  fornix,  fixed  by  the  speculum, 
when  the  globe  rolls  far  upwards.  (The  lower  fornix, 
normally  less  extensive  than  the  upper,  was  also  in  our 
cases  frequently  more  or  less  retracted  by  scarring). 
These  dangers,  however,  can  be  guarded  against  by  ex- 
tracting the  lens  subconjunctivally,  and  by  substituting 
retractor  and  finger  depression  for  the  speculum.  But 
still  the  great  drawback  of  all  lower  sections  remains — 
viz.,  the  placing  of  the  coloboma  below  whenever  an 
iridectomy  has  to  be  made,  whether  of  deliberate  intent, 
or  on  account  of  trouble  during  the  operation,  or  of 
prolapse  afterwards.  It  was  on  this  account  that  the 
upward  section  became  the  routine  practice  for  all  ordinary 
cases.  It  has  been  held  that  all  the  manipulations, 
including  the  delivery  of  the  lens,  are  more  difficult  by 
the  upper  section.  But  this  is  not  so,  provided  the  patient 
looks  steadily  downwards.  On  the  contrary,  to  one  used 
to  the  upper  section,  the  delivery  of  the  lens  is  often  less 
easy  through  the  lower  opening.     The  forceps  cannot  be 


Variations  in  Procedure,  and  their  Value     199 

used  as  mentioned  on  p.  115,  and  it  is  more  difficult  to  cut 
a  satisfactory  conjunctival  flap  below  the  cornea  with  the 
knife.  It  is  a  question  whether  at  least  a  narrow  con- 
junctival bridge  should  not  always  be  left  undivided  in 
operating  below,  and  peripheral  iridectomy  has  special 
claims  (see  later). 

It  has  been  held  that  the  upper  section  exposes  the 
interior  of  the  eye  more  to  possibilities  of  infection,  in  that 
not  only  blood,  but  also  fluids  from  the  surface  of  the 
globe,  possibly  microbe-containing,  more  easily  find  their 
way  into  the  anterior  chamber.  On  the  other  hand, 
should  irrigation  of  the  chamber  be  practised  for  the 
removal  of  cortex,  blood,  etc.,  the  situation  of  the  wound 
above  is  undoubtedly  preferable.  For  it  is  scarcely 
possible  to  irrigate  without  forming  a  pool  of  fluid  in  the 
conjunctival  sac  sufficiently  large  to  cover  a  lower  section, 
thus  connecting  the  interior  of  the  eye  by  moving  currents 
of  fluid  with  a  possibly  foul  lower  fornix. 

Some  form  of  downward  section  is  almost  forced  on  one 
in  the  case  of  patients  who  cannot  be  depended  upon  to 
look  steadily  downwards.  It  is  also  indicated  when  a 
coloboma  already  exists  below,  either  congenital  or  other- 
wise ;  also  for  lenses  dislocated  into  the  anterior  chamber ; 
and  is  performed  by  some  operators  where  the  upward 
section  is  difficult  in  deeply  sunken  eyes,  or  in  eyes  with 
narrow  palpebral  aperture.  Also,  by  Czermak's  method, 
for  dislocated  lenses. 

Outer  Sections. — Section  of  the  outer  portion  of  the  cornea, 
though  largely  practised  for  the  '  linear  extraction '  of  soft 
cataracts,  has  never  become  an  established  procedure  for  the 
removal  of  lenses  with  hard  nuclei.  It  has  been  performed, 
however,  by  a  few  operators.  Daviel  gave  a  trial  to  a 
triangular  section  outwards.  Galezowski  (1871)  performed 
von  Graefe's  scleral  linear  extraction  outwards  with  a  bent  knife. 
Macnamara  (1871),  Castorani  (1874)  and  Andrew  (1883),  all 


200  Cataract  Extraction 

made  a  linear  section  at  the  temporal  margin  of  the  cornea 
with  a  broad  keratome  (Castorani  later  with  Beer's  knife)  and 
removed  the  lens  in  its  capsule  with  a  spoon. 

Bourgeois*  (Rheims)  has  reported  four  perfectly  successful 
simple  extractions  by  an  external  lateral  section  specially 
adapted  for  the  application  of  sutures.  It  is  designed  for 
occasional  use  only — viz.,  in  most  of  the  cases  where  the  appli- 
cation of  sutures  is  indicated  (p.  214),  also  in  very  prominent 
eyes,  and  where  the  palpebral  aperture  is  small,  and  in  totally 
deaf  patients. 

He  uses  a  double  knife f  consisting  of  two  bent  "broad 
needles "  lying  parallel  to  one  another  in  the  same  plane, 
separated  by  a  space  of  i  millimetre.  Their  handles  are 
locked  together  by  a  simple  mechanism,  which  admits  of  their 
being  easily  separated. 

Cocain  having  been  freely  instilled  and  Panas'  speculum 
inserted,  the  globe  is  fixed  at  the  inner  side  by  the  assistant. 
The  puncture  is  made  at  the  limbus,  one  blade  on  either  side 
of  the  horizontal  corneal  meridian.  The  knife  is  held  in  the 
right  hand,  and  this  determines  the  position  of  the  operator  for 
either  eye  in  the  usual  way.  At  the  moment  of  puncture  the 
surgeon  fixes  the  eye  with  his  left  hand,  giving  up  the  forceps 
again  to  the  assistant  immediately  afterwards.  As  soon  as  the 
blades  have  penetrated  well  into  the  anterior  chamber  they  are 
unlocked.  And  while  the  lower  blade  is  held  in  position  with 
one  hand,  the  other  one  is  made  to  cut  upwards  along  the 
corneal  margin  nearly  to  the  vertical  meridian.  It  is  then 
withdrawn,  and  a  similar  downward  incision  made  with  the 
lower  blade.  Thus  two  equal  half  sections  are  made,  separated 
by  a  bridge  of  undivided  cornea,  i  millimetre  broad. 

The  sutures  are  now  inserted,  first  one  at  the  middle  of  the 
lower  half  section,  and  then  one  in  the  corresponding  position 
above.  In  each  case  the  corneal  lip  of  the  wound  is  pierced 
and  the  curved  needle  drawn  completely  through,  before  the 
scleral  lip  is  perforated.  The  loops  of  thread  crossing  the 
wound  are  left  long,  and  turned  out  of  the  way,  upward  and 
downward,  over  pads  of  sterilized  gauze. 

The  corneal  bridge  is  then  divided  with  a  blunt-pointed 
knife.     The  lens  is  extracted  in  the  ordinary  way  after  opening 

*  Anfi.  d'OcuL,  cxxv  (1901),  10. 

t  Made  by  M.  Major,  91  Boulevard  Saint-Germain. 


Variations  in  Procedure,  and  their  Value     201 

the  capsule,  or  it  may  be  removed  in  its  capsule  with  a  small 
spoon.  To  facilitate  this  latter,  Bourgeois  suggests  division  of 
the  pupillary  zone  of  the  iris,  where  necessary,  with  scissors. 
The  threads  are  then  drawn  tight  by  their  scleral  ends  and 
tied.  They  are  left  in  situ  for  five  or  six  days.  A  third  suture 
might  be  placed  at  the  middle  of  the  wound,  if  thought  neces- 
sary, to  prevent  prolapse  of  iris. 

Double  Flap  Sections. — -Schulek*  in  1895,  and  Plehntin 
1901,  published  accounts  of  two  very  similar  double-flap  sections, 
designed  with  the  idea  of  preventing  prolapse  of  iris.  The 
former  used  a  very  narrow  Graefe's  knife,  the  latter  a  special 
trapeziform  instrument.     After  cutting  upwards  in  the  limbus 


Fig.  76. — Schulek's  Incision. 

for  a  portion  of  the  distance  for  an  ordinary  upper  flap,  the 
section  is  continued  at  an  angle  downwards  and  forwards  to 
completion.  Thus,  in  addition  to  a  larger  lower  flap  directed 
upwards,  there  is  formed  a  smaller  overlapping  tongue  of  cornea 
projecting  downwards  from  above.  The  lower  flap  fits  into 
the  groove  behind  the  upper,  and  is  kept  in  place  by  it.  In 
Schulek's  hands  the  method  did  not  prove  effective  against 
prolapse;  his  proportion  was  10  per  cent. 

L.  Mailer  X  has  designed  a  section  which,  by  its  devious 
course  and  by  fixation  with  sutures,  provides  for  very  firm  and 
exact  closure  of  the  wound.  It  is  intended  to  be  used  only  in 
cases  where  the  application  of  sutures  is  indicated  (p.  214). 

The  first  step  is  the  formation  of  a  small  superficial  corneal 
flap  with  its  base  upwards  at  the  limbus.     Its  lateral  measure- 

*  Ungar.  Beitr.  z.  A.,  \  (1895),  254. 
t  Zeitsch.f.  A.,  v  (1901),  259. 
+  Kl.  Mbl.f.  A.,  xli  (1903),  II. 


202 


Cataract  Extraction 


ment  is  5  millimetres,  its  vertical  extent  2  millimetres.  It  is 
made  by  thrusting  a  very  narrow  Graefe's  knife  across  in  the 
substance  of  the  cornea,  with  the  cutting  edge  downwards,  and 
without  going  deep  enough  to  enter  the  anterior  chamber. 
After  cutting  downwards  for  2  millimetres,  the  edge  of  the 
blade  is  turned  directly  forwards.  Thus  the  small  flap,  (a)  (b) 
(c)  (d)  and  (i)  (h)  {g),  is  not  thinned  at  its  extremity,  but  is  cut 
rectangularly. 

Two  sutures  are  now  inserted  through  the  angles  of  the  flap 
at  (c)  and  {d)  into  the  neighbouring  cornea,  but  the  loops  are 
left  loose. 

The  section  is  then  completed  by  an  upward  incision  with  a 


a  b 

Fig.  77. — L.  Muller's  Incision. 

Graefe's  knife,  as  in  making  an  ordinary  3-millimetre  corneal 
flap  section.  [Puncture  and  counter-puncture  at  (e)  and  (/), 
summit  of  the  flap  at  {k)  (i).]  It  must  end,  therefore,  exactly 
at  the  base  of  the  small  superficial  flap,  and  care  must  be 
taken  not  to  cut  into  the  base  of  the  small  flap  at  all. 

The  sutures  are  tied  at  the  close  of  the  operation,  and  are 
not  required  for  longer  than  one  or  two  days,  owing  to  the 
considerable  area  of  the  opposed  surfaces  of  the  wound. 


Subconjunctival  Extraction. 

Where  there  appears  to  be  any  particular  advantage  to 
be  gained  by  it,  the  lens  may  be  delivered  beneath  the 
conjunctiva,  previously  undermined,  and  thence  through 
an  opening  which  does  not  correspond  with  the  sclero- 
corneal  section.  There  are  two  methods  which  have  been 
largely  practised  by  a  few  operators  as  routine  procedure 


Variations  in  Procedure,  and  their  Value     203 

for  the  general  run  of  cases.  The  *  conjunctival  bridge ' 
or  '  adherent  conjunctival  flap '  operation,  first  performed 
with  downward  section  by  Desmarres  in  185 1,  was  ex- 
ploited largely  with  upward  section  in  1899  by  Pansier 
and  Vacher  (Orleans),  independently  of  each  other.  The 
method  is  as  in  the  cutting  of  a  large  conjunctival  flap, 
but  the  knife  is  passed  onwards  under  the  conjunctiva  for 
I  to  1*5  cubic  millimetres,  and  the  making  of  the  flap  is 
not  completed,  a  bridge  as  broad  as  possible,  5  to  8  milli- 
metres, being  left  undivided.  From  this  simple  measure 
Czermak's  '  conjunctival  pouch '  operation  developed, 
affording  an  even  more  effective  covering  to  the  deep 
wound.  The  first  step  was  the  preliminary  undermining 
of  the  conjunctiva  with  scissors  before  making  the  section. 
And  finally,  the  sclero-corneal  section  itself  was  made 
mainly  with  scissors  subconjunctivally. 

The  main  value  of  the  subconjunctival  operations 
obtains  during  the  healing  period.  The  more  complete 
the  covering  of  the  sclero-corneal  wound,  the  more  per- 
fectly is  secondary  infection  excluded.  By  Czermak's 
method  the  protection  appears  complete.  As  a  safeguard, 
however,  against  primary  infection — i.e.,  infection  intro- 
duced during  the  operation — the  advantage  of  the  sub- 
conjunctival methods  of  extraction  is  not  so  definite.  The 
deep  wound  is  certainly  guarded  from  accidental  contact 
with  palpebral  conjunctiva  and  lid  margins  (and  from 
fouling  by  the  operator's  saliva  should  he  not  wear  a 
mask),  but  otherwise  the  possibilities  as  regards  the  entry 
of  micro-organisms  do  not  appear  greatly  altered. 

The  conjunctival  covering  is  not  able  to  retract  like  a 
completely  divided  flap,  and  so  there  is  not  the  subsequent 
separation  of  the  deep  wound  which  forms  one  of  the 
drawbacks  to  a  large  flap,  and  its  rapid  union  with  the 
underlying  tissue  serves  to  prevent  reopening  of  the  wound 


204  Cataract  Extraction 

and  prolapse  of  iris.  Czermak  found  the  eye  practically 
safe  from  iris  prolapse  after  the  first  few  hours  following 
operation.  Vacher  reported  a  series  of  120  extractions, 
mostly  simple,  free  from  prolapse.  In  our  Bombay 
experience  of  Czermak's  operation  we  had  almost  no 
prolapse,  though  the  pupil  was  sometimes  left  somewhat 
distorted  and  displaced.  Against  this,  however,  must  be 
set  the  frequency  with  which  we  had  to  perform  combined 
extraction  (see  below).  Should  prolapse  occur,  it  does  not 
open  a  way  for  infection  of  the  eye,  owing  to  the  pro- 
trusion being  subconjunctival. 

It  is  a  small  advantage  that  the  eyes  thus  operated  upon 
need  less  after-care  than  ordinary,  also  it  is  claimed  that 
there  is  less  astigmatism  caused. 

The  tense  conjunctival  covering  is  of  service  during  the 
operation  in  certain  cases  (p.  211),  in  reducing  the  risk  of 
vitreous  accident. 

The  drawbacks  to  any  subconjunctival  operation  are 
chiefly : 

I.  Undoubtedly  an  enhanced  difficulty  at  times  in 
delivering  the  lens  safely,  and  in  evacuating  lens  remnants. 
The  difficulty  is,  perhaps,  greater  the  more  the  con- 
junctiva is  anchored,  as  it  is  in  the  'pouch  '  method,  and 
where  the  *  bridge '  is  very  broad.  Hence  frequently 
injury  to  the  iris  necessitating  iridectomy,  and  a  tempta- 
tion to  increase  the  pressure  in  expulsion,  to  such  a  degree 
as  to  risk  rupture  of  the  zonule. 

The  iridectomy  is  of  consequence  only  in  the  downward- 
placed  operations.  In  our  earlier  operations  with  con- 
junctival pouch  —  doubtless  owing  largely  to  faulty 
technique — we  had  to  do  combined  extraction  in  about 
half  the  cases,  and  only  quite  at  the  end  did  we  reduce  the 
proportion  of  combined  operations  much  below  one-third. 
In  no  Czermak's  operations  an  iridectomy  was  made  no 


Variations  in  Procedure,  and  their  Value     205 

less  than  46  times,  and  once  excision  of  prolapse  was 
undertaken  afterwards.  The  coloboma,*  situated  down- 
wxrds  and  outwards,  constitutes  a  grave  defect  in  a  patient 
who  requires  very  acute  vision  afterwards. 

2.  The  number  of  vitreous  accidents  attributable  to  diffi- 
cult expulsion  of  the  lens  is  likely,  unless  great  patience  be 
exercised  in  the  expulsion,  to  obscure  the  advantage  of  the 
operation  in  this  respect  in  the  special  cases  above  referred 
to.  In  Bombay  our  proportion  of  vitreous  losses  was 
slightly  higher  in  these  operations  than  in  ordinary  extrac- 
tions. 

3.  The  tendency  to  stripping  of  cortex  in  the  delivery 
of  the  lens  through  a  wound  not  widely  open  renders  sub- 
conjunctival extraction  quite  unsuited  for  cataracts  at  all 
unripe. 

4.  In  spite  of  adrenalin,  hcemorrhage  into  the  anterior 
chamber  may  occasionally  cover  lens  and  iris.  A  small 
quantity  of  blood  may  be  readily  expressed.  But  per- 
sistent bleeding t  from  rigid  blood-vessels  may  fill  the 
chamber  and  the  conjunctival  pocket  (in  Czermak's  opera- 
tion) with  clot,  rendering  the  completion  of  the  operation 

*  In  most  of  our  Indian  patients  the  iridectomy  downwards  could 
not  be  considered  a  very  serious  drawback.  In  some  instances  the 
excision  of  iris  was  to  facihtate  the  delivery  of  the  lens  or  of  lens 
remnants  ;  in  others  to  prevent  prolapse  of  the  iris,  more  or  less 
injured  in  the  expulsion  of  the  lens.  In  most  of  these  latter  cases  the 
complete  coloboma  might  probably  have  been  replaced  by  a  small 
peripheral  opening,  with  little  or  no  effect  upon  vision.  Such  a  small 
iridectomy  might  be  made  downwards  or  downwards  and  inwards 
through  a  small  conjunctival  slit. 

t  In  one  of  our  cases,  already  mentioned  on  p.  162,  there  was 
bleeding  about  the  close  of  the  operation  to  produce  a  considerable 
swelling  under  the  conjunctiva  with  separation  of  the  lips  of  the  deep 
wound  and  bending  forward  of  the  lower  part  of  the  cornea.  There 
was  no  pain,  and  no  loss  of  perception  of  light.  But  the  pupil  became 
closed  with  clot  and  lymph,  and  though  the  iris  was  perfectly  clear, 
needlings  failed  to  provide  an  open  pupil,  and  the  tension  of  the  eye 
remained  low. 


2o6  Cataract  Extraction 

very  difficult,   and   making   it  impossible   to   deal    satis- 
factorily with  the  iris. 

5,  The  slight  prolongation  of  the  operative  procedure  is 
scarcely  noticeable  in  the  narrow  bridge  operation,  but  is 
definite  where  undermining  of  the  conjunctiva  by  scissors 
is  undertaken.  This  is  of  no  importance  in  downward 
sections,  but  appears  to  limit  the  application  of  Czermak's 
upward  section  very  considerably,  owing  to  the  increased 
strain  placed  upon  the  patient's  self-control  in  continuously 
looking  downward. 

Czermak's   Downward    Section  with    Subconjunctival 

Pouch. 

Adrenalin  must  be  combined  with  the  cocain  or  used 
before  it,  and  during  this  operation  the  cornea  needs 
moistening  from  time  to  time  with  sterile  salt  solution. 
The  operator  stands  in  the  usual  position  for  the  right 
eye,  beside  the  patient  for  the  left  eye.  The  patient  turns 
the  eye  somewhat  upward,  and  the  globe  is  fixed  with 
forceps  close  to  the  inner  side  of  the  cornea,  immediately 
above  its  horizontal  meridian.  With  a  broad  (3-milli- 
metre) Graefe's  knife  a  sclero-corneal  puncture  is  made 
close  to  the  limbus  at  the  outer  end  of  the  horizontal 
corneal  meridian,  with  the  cutting  edge  of  the  knife  down- 
wards, as  if  to  cut  a  semicircular  flap  with  the  knife.  The 
puncture  is  made  subconjunctivally  after  engaging  the 
conjunctiva  at  a  little  distance  (2  millimetres)  from  the 
cornea  on  the  point  of  the  knife  and  sliding  it  inwards. 
The  capsulotomy  may,  if  preferred,  be  made  with  the 
point  of  the  knife,  and  the  instrument  is  then  withdrawn. 
Or  the  capsular  opening  may  be  made  later  in  the  usual 
way. 

The  opening  in  the  conjunctiva  is  then  extended  with 


Variations  in  Procedure^  and  their  Value     207 

scissors  obliquely  down  and  out,  nearly  to  the  lower 
fornix.  The  inner  border  of  this  slit  is  now  raised  with 
forceps  and  the  scissors  introduced,  to  undermine  by  a  few 
snips  the  lower  ocular  conjunctiva  from  the  limbus  down- 


FlG.   78. — CZERMAK'S   LoWER   SECTION. 

The  Puncture. 

(From  'Die  Augenarztlichen  Operationen.'') 

wards.  Thus  is  formed  a  subconjunctival  pocket,  as  far 
as  a  vertical  line  falling  from  the  inner  end  of  the 
horizontal  corneal  meridian.  Czermak  holds  it  important 
to  loosen  the  membrane  quite  up  to  the  limbus,  to  enable 


Fig.  79. — Czermak's  Lower  Section. 
The  Cutting. 

[From  'Die  Augenarztlichen  Operationen.') 

the  sclero-corneal  section  to  be  placed  immediately  behind 
the  limbus,  thus  to  reduce  the  chances  of  prolapse  and 
incarceration  of  iris.  At  the  same  time  care  must  be 
taken  to  avoid  perforating  the  conjunctiva  with  the 
scissor  points. 


2o8  Cataract  Extraction 

The  sclero-corneal  section  is  now  completed  with 
scissors.  Czermak  uses  Louis'  scissors,  with  fine  and 
thin  blades,  curved  on  the  flat,  and  with  round  points. 
One  blade  is  i  to  i'5  millimetres  longer  than  the  other. 
Therefore  two  pairs  of  these  scissors  are  required,  one  for 
the  right  eye  and  one  for  the  left.  The  long  blade  is 
introduced  into  the  anterior  chamber  through  the  puncture, 
and  the  other  blade  passed  under  the  conjunctiva.  With 
three  or  four  snips  a  subconjunctival  incision  may  be 
made  as  far  as  the  nasal  end  of  the  horizontal  meridian  of 
the  cornea.  In  cutting,  the  scissors  are  held  obliquely  to 
the  scleral  surface,  so  that  the  curvature  of  the  blades  may 
correspond  with  that  of  the  corneal  margin,  and  a  light 
forward  pull  upon  the  eye  is  maintained  by  the  deep 
blade.  The  little  finger  of  the  cutting  hand  is  supported 
on  the  assistant's  hand,  except  at  the  beginning  of  the 
incision  in  the  right  eye,  when  it  rests  against  the  patient's 
temple. 

The  lens  is  delivered  in  the  ordinary  manner  of  simple 
extraction  by  pressure  above  and  counter-pressure  below. 
The  spatula  or  curette  below  is  introduced  under  the 
conjunctiva.  The  lens  is  pressed  into  the  subconjunctival 
pocket,  and  thence  outwards.  Any  cortical  remains  are 
dealt  with  in  the  same  way,  or  removed  by  irrigation. 

The  iris  frequently  becomes  prolapsed,  and  in  any  case 
needs  to  be  replaced  with  the  spatula  if  the  pupil  is  not 
round. 

A  fine  suture  may  now  be  used  to  close  the  conjunctival 
opening  (I  have  never  sutured  it),  and  finally  eserin  is 
instilled. 

To  remove  the  danger  of  primary  infection  during  the 
operation  as  completely  as  possible,  Czermak  was  careful  not 
to  introduce  any  instrument  into  the  eye  nor  to  raise  the  lip  of 
the  conjunctival  opening  without  first  mopping  up  any  trace  of 


Variations  in  Procedure,  and  their  Value     209 

fluid  which  might  be  lying  in  the  lower  fornix.  The  mouth  of 
the  pocket  was  opened  with  fine  forceps  at  the  time  of  intro- 
duction of  any  instrument,  in  order  that  the  latter  might  not 
come  unnecessarily  in  contact  with  the  conjunctival  surface. 

A  small  modification  of  the  section  is  to  make  not  only  the 
puncture,  but  also  the  counter-puncture  with  the  knife,  and  so 
to  get  over  the  difficulty  which  is  experienced  in  cutting  with 
the  scissors  at  the  nasal  end  of  the  incision  if  the  patient 
does  not  look  upwards.  The  perforation  of  the  conjunctiva, 
however,  leaves  the  sclero-corneal  wound  not  quite  fully 
covered. 

In  our  Bombay  operations  by  this  method  I  nearly  always 
punctured  a  little  above  the  horizontal  meridian  of  the  cornea, 
with  the  knife  pointing  upwards  and  inwards,  and  so  made  the 
flap  downwards  and  a  little  outwards  instead  of  directly  down- 
wards. This,  of  course,  reduces  the  difficulty  in  cutting  with  the 
scissors  at  the  inner  side.  Even  so,  with  a  patient  who  is 
unable  to  fix  his  eye  at  all  upwards,  it  is  well  to  counter - 
puncture  with  the  knife.  If  this  counter-puncture  be  made 
slowly  about  ^  millimetre  behind  the  corneal  margin,  and 
especially  if  the  blade  be  twisted  slightly  at  the  time,  leakage 
of  aqueous  under  the  conjunctiva  may  balloon  it  forwards  out 
of  reach  of  the  point  of  the  knife,  so  preventing  any  perforation 
of  the  conjunctiva.  It  saves  trouble,  also,  to  cut  the  greater 
portion  of  the  temporal  half  of  the  deep  wound  by  sawing 
movements  with  the  knife.  The  section,  as  far  as  the  vertical 
meridian  of  the  cornea,  may  be  readily  made  thus  with  an 
empty  anterior  chamber  and  without  injury  to  the  iris  or  to 
the  conjunctiva,  if  the  simple  precaution  be  taken  to  do  all  the 
actual  cutting  in  the  withdrawal  movements  of  the  knife  (none 
during  the  inward  movements  of  the  blade).  In  one  case  I 
made  the  whole  of  the  section,  including  the  counter-puncture, 
subconjunctivally  with  the  knife. 

Our  difficulties  in  expression  were  lightened  as  soon  as  we 
realized  that  it  was  better  to  remove  the  stop-speculum  and  to 
substitute  Desmarres'  retractor  for  the  upper  lid  and  finger 
depression  for  the  lower  lid,  before  attempting  to  expel  the  lens. 
This  loosens  the  conjunctiva  considerably. 

Finding  it  easier  to  express  (by  means  of  the  tenotomy  hook) 
with  the  right  hand  and  to  apply  counter-pressure  (by  the 
curette)  with  the  left  hand,  I  had  to  change  position  always 

14 


2IO  Cataract  Extraction 

from  the  patient's  head  to  his  side,  or  vice  versa,  after  making 
the  section. 

Our  troubles  in  the  earlier  cases  were  sometimes  due  to 
making  the  section  rather  small,  I  used  only  Stevens'  curved 
strabismus  scissors — one  pair  for  cutting  and  loosening  the 
conjunctiva,  and  a  second  pair  for  the  deep  section.  (Being 
rather  stiff  in  opening,  they  had  usually  to  be  withdrawn  from 
the  wound  between  the  snips.)  In  cutting,  the  scissors  were 
steadied  against  the  left  forefinger.  The  scissor  blades  nearly 
always  got  soiled  by  contact  with  the  lid  margins,  but  not  close 
to  their  points. 

The  deep  wound  may  become  exposed  in  part  owing  to 
perforation  of  the  conjunctiva.  This  may  happen  either  in 
undermining  the  membrane  close  to  the  limbus,  or  during  the 
making  of  the  section  if  any  downward  movement  of  the  eye 
should  then  take  place,  or  if  the  scissor  blades  be  not  held  at 
the  correct  angle  of  obliquity. 

In  one  or  two  of  our  cases  the  base  of  the  iris  was  nipped  by 
the  scissors.  The  weakening  or  perforation  of  the  base  of  the 
iris  increased  the  difficulty  of  forcing  the  lens  through  the  pupil, 
and  so  perhaps  accounted  for  a  few  of  our  iridectomies. 

Among  the  minor  drawbacks  and  complications  of  the 
operation  may  be  mentioned  also  : 

Like  all  downward  sections,  the  wound  is  badly  situated  for 
irrigation  of  the  anterior  chamber,  for  it  is  impossible  to  use 
the  ordinary  irrigator  without  forming  a  pool  of  fluid  in  the 
conjunctival  sac  covering  the  wound.  The  surface  of  the 
conjunctiva  must,  therefore,  be  well  douched  before  any  fluid 
is  allowed  to  enter  the  wound. 

After  operation,  transient  patchy  opacity  of  the  centre  of  the 
cornea  in  its  posterior  layers,  extending  frequently  by  streaks 
to  the  wound  line,  afforded  evidence  of  bruising  of  the  centre 
of  the  cornea  during  the  expression  of  the  lens.  Its  flaky 
appearance  gave  a  close  resemblance  to  bits  of  lens  cortex  left 
in  the  anterior  chamber.  Finally,  at  the  time  of  discharge 
the  tine  posterior  lines  mentioned  under  *  Corneal  Opacity,' 
Chapter  V,  were  frequently  found,  especially  following  early 
cloudy  opacity,  extending  more  or  less  over  the  central  area 
of  the  cornea. 

At  the  time  of  discharge  a  number  of  eyes  were  found  still 
^•ery  soft,  though  there  was  no  visible  separation  of  the  dgep 


Variations  in  Procedure,  and  their  Value     2 1 1 

wound.  The  sclero-corneal  wound  surfaces  made  by  the 
scissors  appear,  therefore,  frequently  slow  in  uniting.  We 
kept  one  of  these  patients  in  hospital  for  three  weeks  after 
operation,  and  still  the  tension  was  very  low. 

Indications. — A.  Where  a  complete  covering  appears 
advisable  or  imperative  to  keep  out  infection. 

1.  In  Bombay  the  operation  was  mostly  performed  from 
fear  of  infection  from  an  unhealthy  conjunctiva,  discharging 
slightly.  Danger  from  any  slight  inflammation  about  the 
lids  might  be  similarly  guarded  against.  If  the  fellow  eye 
had  been  lost  by  suppuration  following  cataract  extraction, 
the  subconjunctival  method  would  seem  to  be  indicated. 

2.  Very  unhealthy  patients  need  all  the  protection  they 
can  get,  on  the  supposition  that  their  tissues  cannot  be 
expected  to  cope  with  even  very  few  and  but  feebly  patho- 
genic micro-organisms.  This  applies  particularly  to 
albuminurics  with  marked  anaemia  and  some  cedema  about 
the  ankles. 

3.  In  rare  cases  where  prolapse  or  loss  of  vitreous  seems 
likely  to  occur,  preventing  immediate  closure  of  the  wound, 
it  is  well  that  the  wound  shall  be  covered  as  completely  as 
possible.  This  applies  for  a  lens  dislocated  into  the 
anterior  chamber.  For  such  a  lens  the  operation  is  also 
indicated,  on  account  of  the  position  of  the  wound,  and  the 
mode  of  making  of  it  with  scissors.  These  claims  hold  in 
spite  of  the  possible  drawback  of  having  to  make  a 
coloboma  in  the  iris  downwards.  But  I  think  Czermak 
was  wrong  in  advising  this  method  for  partially  dislocated 
and  tremulous  lenses,  because  in  such  eyes  the  utmost 
gentleness  and  freedom  of  manipulation  are  demanded  in 
extracting  the  lens. 

B-  To  reduce  the  risk  of  vitreous  loss  during  operation. 
Nervous,  frightened  patients,  who  jerk  their  eyes  about 
on  small  provocation,  and  are  thus  very  liable  to  accident 

14 — 2 


2  12  Cataract  Extraction 

under  the  ordinary  operation,  behave  remarkably  well 
during  Czermak's  operation.  This  is  largely  owing  to  the 
degree  of  anaesthesia  induced  by  the  combination  of 
adrenalin  and  cocain.  Their  quietude  is  further  assured, 
in  that  they  are  not  worried  with  instructions  to  keep  their 
eyes  strongly  rotated  in  any  direction. 

Further,  the  wound  cannot  well  be  forced  open  by 
spasmodic  closure  of  the  lids,  nor  can  it  be  pulled  open  by 
extreme  vertical  movements  of  the  globe.  This  advantage 
is  greatest  in  exophthalmos  and  where  the  fornices  are 
much  retracted  by  scarring.  In  tremor  capitis  and  marked 
nystagmus  this  operation  is  the  safer. 

C.  Czermak's  operation  may  well  become  almost  the  only 
downward  section  practised,  as  it  is  distinctly  superior  to 
the  ordinary  lower  section.  In  Bombay  we  used  the 
method  in  stupid  patients  who  were  unable  to  look 
steadily  downwards  after  a  little  training,  and  we  were 
thus  saved  much  worry.  In  very  deaf  patients  the  same 
would  apply.  In  other  conditions  which  call  for  the 
lower  operation,  such  as  the  presence  of  a  coloboma  below, 
congenital  or  manufactured,  Czermak's  method  is  suitable. 
It  may,  however,  be  impracticable,  owing  to  adherent 
leucoma  or  anterior  synechia,  or  in  rare  cases  of  scarring 
of  the  ocular  conjunctiva,  from  injury  or  otherwise.  In 
patients  in  a  state  of  dementia  the  method  appears 
advisable  on  grounds  both  B  and  C,  also  on  account  of 
the  lightened  after-care. 

D.  A  very  occasional  indication  for  the  scissor  section 
is  where  during  the  ordinary  operation  the  anterior 
chamber  becomes  emptied  accidentally  soon  after  the 
puncture  has  been  made.  The  puncture  being  above  the 
horizontal  corneal  meridian,  Czermak  would  have  com- 
pleted the  operation  upwards  with  iridectomy.  But  unless 
iridectomy  seems  likely  to  be  called  for,  a  section  down- 


Variations  in  Procedure,  and  their  Value     2 1 3 

wards  and  outwards  is  applicable,  especially  in  patients 
who  cannot  be  expected  to  maintain  prolonged  downward 
fixation. 

Czermak  also  made  a  similar  upward  section  in  eyes  where 
iridectomy  was  likely  to  be  needed.  The  piece  of  iris  was 
removed  through  a  minute  vertical  conjunctival  puncture. '•' 
As  already  mentioned,  the  great  objection  to  this  operation  is 
that  the  long  period  of  downward  fixation  required  would 
appear  to  place  a  considerable  strain  upon  the  patient's  self- 
control.  In  this  important  respect  it  presents  a  great  contrast 
with  the  downward  scissor  section,  which  is  comparatively 
easy  of  performance,  and  does  not  need  the  co-operation  of  the 
patient  at  all. 

When  a  tense  covering  is  desired  for  an  upward  section,  as 
in  an  eye,  glaucomatous  or  otherwise,  where  vitreous  tension 
probably  exists,  or  where  there  is  persistent  cough,  dyspnoea, 
or  straining  in  micturition,  the  necessary  conjunctival  bridge 
can  be  fashioned  sufficiently  well  and  quickly  with  the  knife. 
Should  a  very  complete  covering  be  desired,  the  site  of  the 
puncture  may  be  covered  by  sliding  the  conjunctiva,  and  that 
of  the  counter-puncture  by  bringing  the  point  of  the  knife  out  a 
fraction  of  a  millimetre  further  away  from  the  corneal  margin 
than  usual  (p.  79).  Thus,  the  '  bridge '  will  probably  usually 
replace  the  '  pouch  '  above  the  cornea.  Below  the  cornea  a 
conjunctival  bridge  may  still  occasionally  be  made  where  for 
any  reason  the  scissor  section  of  the  sclera  and  cornea  is 
inapplicable. 

Kuhnt  has  employed  a  double-pedicled  band  of  conjunctiva 
for  covering  the  cataract  incision,  outlined  and  undermined 
beforehand.  The  two  attached  ends  are  situated  laterally.  It 
has  been  used  as  a  prophylactic  against  infection  in  unruly 
patients  and  in  those  suffering  from  emphysema,  bronchiectasis, 
ozaena,  chronic  rhinitis,  etc. 

Wound  Suture. — Suturing  the  wound,  first  used  in  cataract 
extraction  by  Williams  f  (Boston)  in  1867,  has  been  tried  by 
various  operators.     The  sutures,  at  first  applied  at  the  close  of 

*  Liebreich's  iris  forceps  were  used,  in  order  not  to  stretch  the  small 
conjunctival  opening. 
t  Corigres  de  Londres  :  Compte  rendu,  1873,  p.  174. 


2  14  Cataract  Extraction 

the  operation,  were  inserted  by  Czermak  immediately  after 
making  the  section.  Suarez  de  Mendoza*  made  an  incision 
at  the  Hmbus  only  two-thirds  or  three-quarters  through  the 
cornea  from  the  anterior  surface,  and  then  applied  the  sutures 
before  opening  the  anterior  chamber.  Bourgeois,  using  a 
special  double-bladed  knife,  is  able  to  leave  a  minute  central 
bridge  of  tissue  undivided  till  after  the  threads  are  inserted. 
L.  Miiller,  in  a  complicated  incision,  inserts  the  sutures  before 
the  anterior  chamber  is  opened.  Kaltf  and  others  applied 
them  before  beginning  the  section.  They  have  been  employed 
either  (i)  as  a  routine  procedure,  to  guard  against  prolapse  of 
iris  more  particularly ;  or  (2)  in  selected  cases  only,  where 
there  was  reason  to  fear  loss  of  vitreous  or  displacement  of 
the  corneal  flap  or  expulsive  haemorrhage ;  or  (3)  later,  in  the 
healing  period,  to  bring  together  wound  margins  separated  by 
extensive  prolapse  of  iris  or  vitreous,  or  by  anteflexion  of  the 
cornea.  I  have  had  personal  experience  of  the  corneal  suture 
only  in  certain  glaucoma  operations.  As  applied  to  the 
ordinary  upper  cataract  incision  it  is  altogether  too  difficult 
and  complicated  a  measure,  placing  too  great  a  strain  upon 
the  patient  for  general  use.  Its  application  to  a  lower  or  outer 
section  is  simpler  and  easier.  But  it  has  to  compete,  as 
regards  both  usefulness  and  safety,  with  other  measures,  more 
particularly  subconjunctival  extraction. 

As  a  preventive  of  prolapse  a  single  suture  has  not  proved 
always  successful.  Kalt  had  four  prolapses  in  fifty  operations, 
Czermak  two  prolapses  in  ten  cases,  Schweigger  six  prolapses 
in  twenty-seven  operations.  As  a  safeguard  against  secondary 
infection,  the  sutures,  though  not  going  through  the  whole 
thickness  of  the  cornea,  and  therefore  not  entering  the  anterior 
chamber,  are  perhaps  not  altogether  free  from  suspicion. 

But  sutures  should  perhaps  serve  best  to  keep  the  wound 
firmly  closed  after  operation.  They  may  thus  prevent  vitreous 
prolapse  in  patients  of  feeble  intelligence,  or  when  delirium  is 
feared  (e.g.,  in  drunkards),  or  in  very  old  people  who  cannot  be 
kept  recumbent,  or  after  operation  for  luxated  or  subluxated 
or  tremulous  lenses,  or  in  glaucomatous  eyes  and  eyes  with 
vitreous  tension,  or  where  there  is  severe  bronchitis,  asthma, 
etc.,   or  where  the   fellow   eye   has    been   lost   by   expulsive 

*  ArcA.  d'OpAL,  ix  (1889),  444. 
■      t  ^./.  ^.,  XXX  (1895),  15- 


Variations  in  Procedure,  and  their  Value     2 1 5 

haemorrhage.  Apparently  vitreous  presenting  in  the  open 
wound  at  the  close  of  the  operation  may  sometimes  be  made  to 
recede  without  any  of  it  being  lost  by  the  tightening  of  the 
sutures.  Kuhnt  has  ?poken  well  of  suturing  in  special  cases. 
During  operation,  however,  there  is  no  help  to  be  got  from 
sutures  as  there  is  sometimes  from  the  subconjunctival  method 
of  operating — eg.,  in  the  case  of  unruly  patients  in  whom 
blepharospasm  and  movements  of  the  globe  are  to  be  feared. 
The  simplest  way  of  obtaining  double  traction  across  the 
wound  is  to  pass  the  fine,  sharp,  and  curved  needle  and  thread 
horizontally  about  3  millimetres  in  the  cornea  and  back  again 
in  the  sclerotic.  The  loop  of  thread  lying  across  the  proposed 
line  of  incision — left  long  during  the  making  of  the  section  and 
the  completion  of  the  operation,  and  kept  as  clean  as  possible 
by  resting  on  a  sterile  pad  of  wool — forms  one  band  across  the 
wound  when  tightened  up,  and  the  ends  of  the  thread  tied 
together  form  the  second. 


\  Fig.  80. — Wound  Suture. 

Sutures  have  been  applied,  also,  to  the  conjunctival  flap  by 
Williams  (Boston),  Kuhnt,  Maddox,  and  others.  Williams  in 
eleven  cases  had  one  prolapse.*  Komoto  (Japan)  has  fixed  a 
long  conjunctival  flap  by  means  of  a  suture  passed  through  the 
tendon  of  the  superior  rectus. 

Ellett  f  (Memphis),  to  guard  against  infection  in  a  case  of 
intractable  chronic  conjunctivitis,  separated  the  conjunctiva 
around  the  whole  of  the  cornea  before  operation,  as  for  enuclea- 
tion. Afterwards  he  drew  the  edges  of  the  conjunctiva  together 
over  the  cornea  with  sutures  horizontally  placed.  The  stitches 
were  removed  after  four  days.  Three  days  later  the  conjunc- 
tiva had  retracted  to  its  normal  position.  The  case  did  well, 
though  the  conjunctival  discharge  persisted. 

*  Boston  Med.  and  Surg.  Journal.,  April  i6,  1896. 
t  Ophth.  Record.^  1903- 


2i6  Cataract  Extraction 

SIMPLE  EXTRACTION. 

No  question  in  eye  surgery  has  been  more  discussed 
than  the  merits  and  defects  of  the  two  methods  of 
operating,  with  and  without  iridectomy.  Opinions  have 
varied  much,  and  apart  from  preconceived  ideas  practice 
has  been  influenced  by  the  conditions  of  operating,  the 
quahty  of  the  nursing,  and  the  skill  and  experience  of  the 
surgeon  and  of  his  assistant. 

Not  only  has  each  method  of  operating — the  combined 
and  the  simple — claimed  strong  partisans,  but  the  opinions 
of  individual  operators  have  veered  from  one  extreme  to 
the  other  with  their  varying  experience.  One's  attitude 
in  the  matter  is  doubtless  largely  controlled  by  tempera- 
ment. Most  beginners  rightly  practice  the  combined 
method  exclusively,  and  many  experienced  operators  have 
been  content  to  continue  throughout  with  the  more  certain 
attainment  of  thoroughly  useful  results.  Whereas  others, 
desiring  the  best  attainable,  have  not  been  deterred  by 
occasional  accidents  from  aiming  at  the  ideal.  Most 
surgeons  nowadays  recognize  that  this  unsettled  question, 
like  practically  all  others  in  cataract  work,  is  one  for  the 
exercise  of  eclectic  principles.  Each  of  the  two  opera- 
tions may  claim  an  indisputable  field  of  applicability,  but 
the  boundary  line  between  them  must  ever  be  a  very  loose 
one.  The  question  is  no  longer,  Which  is  the  better 
method  ?  But  rather,  In  which  cases  should  the  simple 
operation  be  attempted  ?  Selection  of  cases  is  needed  for 
simple  extraction,  since  some  only  are  suitable,  whereas 
all  senile  operable  cataracts  are  alike  fit  for  the  combined 
operation. 

Differences  of  opinion  hinge  largely  on  the  varying 
appreciation  of  the  value  of  the  round  mobile  pupil 
obtained,  when  all  goes  well,  by  simple  extraction.     Most 


Variations  in  Procedure,  and  their  Value     2 1 7 

of  the  patients  are  too  old  to  care  much  about  the  dis- 
figurement of  the  coloboma  of  the  combined  operation. 
This  may,  indeed,  be  scarcely  noticeable  in  dark  eyes,  or 
may  be  covered  by  the  upper  lid  if  the  palpebral  aperture 
be  rather  narrow.  It  has  never  been  shown  that  the 
visual  acuteness  of  the  eye,  as  corrected  by  glasses,  is  at 
all  impaired  by  the  addition  of  the  coloboma  to  the 
pupillary  area,  and  by  the  accompanying  enlargement 
and  sluggishness  of  the  pupil.  Increased  frequency  and 
degree  of  some  minor  visual  defects  must  be  admitted  as 
due  to  iridectomy,  but  mainly  to  a  wide  iridectomy. 
Exposure  to  strong  sunlight  has  in  some  cases  caused 
much  disablement  from  dazzling,  even  though  the  visual 
acuteness  was  good.  It  has  also  been  responsible  for 
retinal  exhaustion  and  erythropsia.  Another  disadvantage 
of  a  wide  coloboma  acknowledged  by  von  Graefe,  is 
defective  orientation  from  poor  peripheral  vision.  On  the 
whole,  the  gain  from  a  small  active  pupil  is  too  slight  to 
justify  any  large  risks  or  sacrifices. 

The  penalties  incurred  by  the  simple  method  are  seen  in 
the  complications  met  with — prolapse  of  iris  and  trouble 
with  lens  cortex.  The  weak  point  of  the  operation  is 
universally  admitted  to  be  the  tendency  to  iris  prolapse 
with  all  its  attendant  evils,  iritis,  irido-cyclitis,  sympa- 
thetic ophthalmia,  cystoid  scar,  staphyloma,  and  astig- 
matism. A  prolapse  rate  of  5  to  10  per  cent,  is  a  serious 
matter,  considering  that  the  protrusion  of  simple  extrac- 
tion is  often  too  large  to  be  completely  excised.  In  spite  of 
treatment,  incarceration  of  the  iris  in  the  scar  may  be  left, 
with  its  permanent  drawbacks  and  dangers.  In  the  com- 
bined operation  entanglement  of  the  iris  in  the  wound  is 
much  more  regularly  preventable.  And  the  inclusions, 
besides  being  less  frequent,  are  smaller ;  they  are  -mere 
incarcerations  and  small  prolapses.    It  seems  strange  that 


2i8  Cataract  Extraction 

these  small  entanglements  (of  divided  iris)  have  been 
blamed  more*  as  excitants  of  destructive  irido-cyclitis 
and  sympathetic  ophthalmia  than  have  the  larger  pro- 
trusions (of  the  unwounded,  uninjured  iris)  of  the  simple 
method. 

Is  it  not  simply  that  incarcerations  are  often  left  un- 
treated, to  give  rise  to  infection,  while  prolapses  more 
insistently  demand  excision  ?  Our  Bombay  experience, 
indeed,  led  us  to  regard  the  small  entanglements  of 
combined  extraction  as  distinctly  less  prone  to  excite  iritis 
and  irido-cyclitis  than  the  large  prolapses  of  the  rival 
method.  And  it  was  thought  that  this  difference  was  due 
to  the  fact  that  the  small  inclusions  were  more  often  com- 
pletely covered  by  the  conjunctival  flap  than  the  larger 
ones.  And  our  operative  experience  in  the  treatment  of 
glaucoma  warranted  us  in  anticipating  a  very  considerable 
permanent  protection  from  this  conjunctival  covering. 

The  operation  without  iridectomy  is  almost  free  from  risk 
of  impaction  of  capsule  in  the  wound,  an  accident  possibly 
quite  as  harmful  as  impaction  of  the  iris.  But  this  is  a 
comparatively  rare  complication  in  a  properly  performed 
extraction  with  iridectomy. 

Judging  from  our  Bombay  experience,  too  much  has 
been  made  of  the  liability  of  impactions  and  adhesions  of 
iris  and  of  capsule  to  give  rise  to  glaucomat  after  the 
combined  operation.  In  this  respect  we  found  little  cause 
to  fear  either  obvious  incarcerations  of  iris,  or  the  adhesions 
of  one  or  both  pillars  of  the  coloboma  to  the  line  of  the 
wound,  almost  constantly  met  with.  The  drawing  forward 
of  the  iris  by  these  frequent  minute  adhesions  to  the  peri- 
pherally situated  scar  must  be  generally  almost  inappreci- 
able.    Though  the  combined  operation  is  the  more  fre- 

*  E.g.^  by  de  Wecker,  Ann.  (VOcul.^  xciv  (1885),  29. 
t  See  Chapter  V. 


Variations  in  Procedure,  and  their  Value     2 1 9 

quently  followed  by  glaucoma,  this  can  be  reckoned  but  a 
comparatively  small  drawback  compared  with  the  dis- 
advantage of  iris  prolapse  after  simple  extraction.  For 
secondary  glaucoma  is  always  uncommon ;  in  Bombay, 
so  far  as  we  could  tell,  it  was  quite  rare,  for  the  reason 
already  given. 

In  extraction  without  iridectomy  cortex  is  more  often 
left  in  the  eye,  especially  behind  the  upper  part  of  the  iris, 
in  spite,  perhaps,  of  more  regular  use  of  irrigation  and 
more  prolonged  manipulation.  It  has  been  held*  that 
this  does  not  apply  in  patients  over  fifty-five  years  of  age, 
when  the  layer  of  soft  cortex  in  the  lens  is  thin  and  comes 
away  readily  with  the  nucleus.  But  this  has  not  been  my 
experience.  Hence  sometimes  tedious  and  prolonged  after- 
treatment,  controlling  iritis,  or  waiting  for  the  absorption  of 
lens  matter.  Hence  also  rather  more  frequent  needling 
required  for  after-cataract.  Also  it  must  not  be  forgotten 
that  the  more  frequent  need  for  fairly  prolonged  irrigation 
during  operation  may  be  counted  as  a  definite  drawback  in 
itself.  As  regards  retained  cortex  and  after-cataract,  it  may 
be  stated  that  after  simple  extraction  there  is  more  chance 
of  the  pupillary  area  being  entirely  occupied  temporarily  by 
opaque  tissue  than  there  would  be  if  the  possible  visual 
area  were  enlarged  by  the  addition  of  a  coloboma.  But 
after  needling,  the  advantage  more  often  lies  on  the  other 
side.  An  entirely  black  pupil  is  more  probable  the  smaller 
its  area.  With  a  large  coloboma  the  vision  may  be  a 
little  reduced  by  diffusion  of  light  through  grey  patches 
beside  the  clear  area. 

Owing  to  the  risk  of  these  complications,  iris  prolapse 
and  cortex  remaining  behind,  the  results  of  simple  extrac- 
tion are  admittedly  less  certain  than  of  the  combined 
operation.     Though  the  percentage  results  may  work  out 

*  Cf.  Czermak,  '  Die  Augenarztlichen  Operationen,'  S.  973. 


2  20  Cataract  Extraction 

as  well  for  the  former  as  for  the  latter,  the  comparison 
must  take  into  account  the  selection  of  cases.  The  cases 
least  favourable  for  operation  are  relegated  to  the  com- 
bined list.  The  result  of  such  comparison,  favourable  as 
it  may  be  to  the  combined  operation,  does  not,  however, 
necessarily  indicate  an  all-round  superiority  of  the  latter. 
It  merely  emphasizes  the  need  of  careful  selection. 

Various  other  advantages  and  disadvantages,  of  minor  import- 
ance or  ill  substantiated,  have  been  urged  for  and  against  each 
method.  The  simple  operation  is  held  to  be  the  quicker  of  the 
two ;  by  some  operators  the  easier,  and  by  opponents  more 
difficult.  It  is  claimed  that  the  operation  is  simplified  by  the 
omission  of  one  step  which,  by  the  way,  is  not  infrequently  a 
slightly  painful*  one.  The  feeling  of  the  majority — viz.,  that 
simple  extraction  undoubtedly  often  proves  the  less  simple  in 
performance — is  echoed  in  the  general  instruction  to  beginners 
to  confine  themselves  to  the  combined  method.  The  difficulty 
experienced  in  delivering  a  firm  sharp-edged  lens  without 
stretching  and  bruising  the  iris,  cannot  always  be  avoided  by 
making  the  regulation  incision,  including  three-sevenths  to  one 
half  of  the  corneal  circumference.  Also  there  is  the  trouble  with 
cortex  already  mentioned. 

The  larger  incision  demanded  by  the  simple  method  cannot 
nowadays  be  considered  a  drawback,  except  in  so  far  as  it 
predisposes  to  accidental  reopening  of  the  wound  and  conse- 
quent prolapse  of  iris,  sufficiently  noted  above. 

It  has  been  counted  as  one  of  the  advantages  of  combined 
extraction,  that  it  permits  of  the  section  including  an  extensive 
conjunctival  flap,  but  with  care  the  same  section  may  be  used 
for  simple  extraction  (p.  225).  The  simple  method  certainly 
at  times  necessitates  slightly  less  instrumentation,  and  thereby 
possibly  less  chance  of  introducing  infection.  But  the  relative 
incidence  of  infective  inflammations  has  been  connected  almost 
entirely  with  the  scar  results  already  discussed. 

Loss  of  vitreous  has  been  said  to  follow  the  simple  operation 
less  often  than  the  combined.     Drake- Brockman,+  comparing 

*  Bleeding  from  the  cut  iris  has  been  mentioned  also  as  a  draw- 
back to  the  combined  method.     See,  however,  p.  98. 
t   The  Ophthalmoscope^  v  (1906),  123. 


Variations  in  Procedure,  and  their  Value     221 

the  two  methods  in  equal  numbers  of  cases  from  his  own 
practice,  293  of  each  operation,  gave  percentages  of  i'o2 
and  5*8  vitreous  losses.  Marshall's  Moorfields  figures"  from 
1889-93,  showed  only  a  small  difference — 2*99  per  cent,  and 
375  per  cent. 

The  risk  of  prolapse  of  iris  renders  simple  extraction  seldom 
applicable  for  private  work  in  a  patient's  house  unless  one  is 
prepared  to  visit  the  case  next  day  with  an  assistant,  prepared 
to  excise  iris,  if  necessary.  On  this  account  I  have  scarcely 
ever  adopted  the  method  in  private  operations.  (Czermak's  sub- 
conjunctival operation  is  almost  free  from  this  objection.) 

The  Selection  of  Cases. — The  cataract  must  be  ripe, 
or  its  removal  will  be  incomplete.  It  must  not  be  very 
overripe,!  with  opaque  capsule  to  be  extracted. I  And 
tremulous  and  subluxated  lenses,  also  cataracts  in  eyes 
with  presumptive  (in  high  myopia)  or  certain  disease  of 
vitreous,  all  demanding  the  easiest  possible  delivery  of  the 
lens,  are  excluded.  Also  usually  '  black  '  cataracts — hyper- 
sclerotic  lenses — too  large  to  pass  easily  through  the 
pupil.  (In  general,  the  older  the  patient  the  more  often 
may  iridectomy  be  needed  on  account  of  the  large  size  of 
the  lens.) 

An  iridectomy  may  be  necessitated  by  a  small  and  rigid 
pupil,  §  or,  for  optical  reasons,  by  central  corneal  opacity. 
For  both  optical  and  mechanical  reasons  by  synechise, 
anterior  or  posterior,  it  being  necessary  to  provide  space 

*  R.  L.  O.  H.  Rep.,  xiv,  56. 

t  Morgagnian  cataracts,  though  overripe,  are  very  suitable  for 
simple  extraction  if  they  happen  to  possess  transparent  or  nearly 
transparent  capsules,  as  they  not  infrequently  do. 

\  The  Punjab  operators,  Mulroney  and  Smith,  extracted  lenses  in 
their  capsules  without  iridectomy.  But  Smith  now  performs  these 
operations  preferably  with  iridectomy. 

^  The  rigidity  of  pupil  may  have  been  noticed  by  very  imperfect 
dilatation  in  the  dark  room,  and  later  under  the  influence  of  cocain. 
Otherwise  it  may  not  be  noticed  till  an  attempt  is  made  to  expel  the 
lens,  when  it  may  be  one  of  the  troubles  which  transform  an  intended 
simple  extraction  into  a  combined  one. 


222  Cataract  Extraction 

for  the  passage  of  the  lens.  Glaucoma,  primary  or 
secondary,  necessitates  a  wide  coloboma.  Though  this  is 
commonly  made  beforehand,  it  need  not  be  always  so 
(Chapter  VI),  especially  in  India,  where  the  patients  will 
not  usually  wait  for  the  two  separate  operations.  Also 
iridectomy  must  generally  be  performed  in  eyes  with  very 
shallow  anterior  chamber.* 

The  conjunctiva,  and  still  more  the  lacrymal  passages, 
must  be  healthy,  so  that  if  prolapse  should  occur  the  iris 
may  not  be  exposed  to  the  attack  of  pathogenic  organisms. 
The  patient  must  be  quiet  and  sensible,  behaving  well 
under  the  usual  tests  for  lid  control  and  globe  fixation. 
There  must  be  no  clonic  spasm  of  the  lids,  and  no  general 
condition  present  likely  to  interfere  with  the  healing  of  the 
wound.  Among  such  may  be  mentioned  a  chronic  cough, 
dyspnoea  from  any  cause,  straining  at  micturition  or  at 
stool,  also  a  feeble  intellect,  epilepsy,  extreme  old  age  and 
extreme  obesity.  Also  there  should  be  no  special  reason 
to  fear  iritis  afterwards,  as  in  diabetes  or  albuminuria. 

If  the  sight  of  the  fellow  eye  has  been  lost,  the  combined 
operation  is  nearly  always  indicated.  Outside  conditions 
should  be  satisfactory — e.g.,  the  surgeon  sufficiently  ex- 
perienced (Pagenstecher),t  and  the  nursing  good,  and 
there  must  be  no  occasion  for  general  anaesthesia. 

*  These  eyes  are  mostly  debarred  from  the  simple  operation  by  the 
fact  that  the  cataract  is  seldom  quite  ripe.  There  is  generally  some 
transparent  cortex  present.  Should  this,  however,  not  be  the  case, 
simple  extraction  may  be  attempted  if  preferred.  That  is  to  say,  the 
larger  section  of  the  simple  method  may  be  made.  Iridectomy  then 
may,  or  may  not,  prove  necessary  on  account  of  injury  to  the  iris 
by  the  knife,  or  through  trouble  w^ith  the  copious  soft  cortex  present, 
or  possibly  on  account  of  vitreous  tension.  Should  this  latter 
condition  chance  to  be  present,  the  larger  wound  will  prove  a  distinct 
disadvantage.  My  personal  preference  is  for  the  combined  operation, 
with  smaller  incision,  in  all  eyes  with  marked  shallowing  of  the 
chamber. 

t  Kl.  M.J.  A.,  xxxii  (1894),  359.  : 


Variations  in  Procedure,  and  their  Value     223 

An  operation  begun  as  a  simple  extraction  not  infre- 
quently becomes  a  combined  one.  This  happens  most 
often  from  over-stretching  or  bruising  of  the  sphincter  of 
the  pupil ;  also  from  scraping  or  wounding  of  the  iris  by 
the  knife,  or  nipping  with  capsule  forceps.  Seldom  on 
account  of  vitreous  tension  or  vitreous  prolapse  or  escape. 
Sometimes  because  the  lens  refuses  to  rotate  forward  easily 
into  the  pupil  (still  more  should  it  have  become  partly  dis- 
located during  the  opening  of  the  capsule),  or  because  of 
cortex  remaining  impacted  behind  the  iris.  Or,  again,  the 
change  may  be  due  to  the  patient  proving  unexpectedly 
deficient  in  self-control. 

It  is  only  rarely  that  one's  intention  becomes  altered  in 
the  reverse  way — i.e.,  that  an  operation  meant  to  be  a 
combined  one  is  ended  without  iridectomy.  This  happens 
when  a  considerable  early  prolapse  of  vitreous  renders 
iridectomy  unnecessary  by  displacing  the  iris  backwards. 

A  few  years  ago  the  number  of  simple  extractions  performed 
at  the  C.  J.  Hospital,  Bombay,  was  about  half  that  of  the' 
combined  operations  (The  Practical  Details  of  Cataract  Extrac- 
tion, second  edition,  p.  63).  The  small  proportion  was 
explained  by  the  number  of  unripe  cataracts  operated  upon, 
also  by  the  frequently  unsatisfactory  state  of  the  conjunctiva, 
and  by  frequent  injury  to  the  iris  through  using  slightly 
blunted  knives,  and  by  the  want  of  proper  nursing.  Later  the 
proportion  fell  considerably  lower.  But  quite  at  the  end  of  my 
time  in  Bombay,  when  the  advantages  of  adrenalin  had  been 
realized,  simple  extractions  were  becoming  more  frequent  than 
combined. 

The  Performance  of  simple  extraction  is  in  principle 
merely  the  operation  already  fully  described,  minus  one 
important  step.  In  practice  differences  have  to  be  em- 
phasized at  each  stage  of  the  operation. 

It  is  a  question  whether  adrenalin  should  not  be  used 
regularly  with  cocain  in  the  eye  before  simple  extraction. 


2  24  Cataract  Extraction 

This  was  our  practice  in  Bombay  latterly,  having  been 
begun  and  having  proved  satisfactory  in  subconjunctival 
extractions  by  Czermak's  method.  Under  the  combined 
influence  of  the  adrenalin  and  cocain  the  pupil  was  found 
enlarged  at  the  time  of  operation.  The  degree  of  dilatation 
was  at  times  only  moderate,  at  other  times  considerable. 
The  pupil  was  generally  not  quite  round  and  also  somewhat 
displaced,  perhaps  most  often  downwards.  The  enlarge- 
ment of  the  pupil  seemed  to  us  particularly  helpful,  in  that 
it  persisted  fairly  well  after  the  anterior  chamber  had  been 
opened.  The  passage  of  the  lens  through  the  pupil  with- 
out injury  to  the  iris  was  appreciably  facilitated,  thus 
lessening  the  risk  of  subsequent  prolapse.  The  value  of 
the  adrenalin  lasted  after  the  operation.  Eserin  solution, 
4  grains  to  the  ounce,  being  instilled  once  or  twice  (with 
an  interval  of  one  minute)  at  the  close  of  the  operation,  its 
action  upon  the  pupil  was  enhanced  by  the  localizing 
influence  of  the  adrenalin.  It  thus  sufficed  to  overcome 
the  dilatation,  and  almost  invariably  next  day  a  quite  small 
pupil  was  found,  guarding  against  prolapse  of  the  iris. 
The  liability  to  this  complication  was  also,  perhaps,  some- 
what reduced  by  the  mental  quietude  of  the  patient 
during  and  after  operation,  attributable  to  the  more 
complete  anaesthesia. 

The  section  must  be  of  full  size,  including  three-sevenths 
to  one-half  of  the  corneal  margin,  without  regard  to  the 
nature  and  size  of  the  cataract.  The  base  of  the  flap 
must  thus  be  brought  low  down,  nearly  or  quite  level  with 
the  centre  of  the  pupil,  in  order  that  free  immediate 
rotation  of  the  lens  upon  its  horizontal  axis  may  be 
provided  for,  without  preliminary  upward  sliding  of  the 
lens.  It  is  more  important  also  that  the  knife  shall  be 
quite  sharp,  and  the  first  inward  thrust  should  perhaps  be 
made  rather  more  quickly  than  in  the  combined  operation, 


Variations  in  Procedure,  and  their  Value     225 

so  that  the  edge  of  the  knife  shall  in  general  reach  almost 
the  summit  of  the  anterior  chamber  in  the  one  movement. 
It  is  important  that  the  greater  part  of  the  section  shall  be 
completed  with  some  aqueous  still  in  the  anterior  chamber, 
and  that  the  final  sawing  action  of  the  knife  shall  be  as 
restricted  as  possible.  Otherwise  the  iris  must  be  rubbed 
and  injured  by  the  blade,  and  this  tends  greatly  to  the  sub- 
sequent occurrence  of  prolapse. 

There  is  a  general  feeling  that  the  section  should  not  lie 
at  all  behind  the  superficial  sclero-corneal  junction,  but 
this  admits  of  dispute.  Allowing  that  proximity  of  the 
wound  to  the  base  of  the  iris  increases  the  tendency  to 
prolapse,  yet  it  by  no  means  follows  that  a  sclero-corneal 
incision  should  always  be  accompanied  or  preceded  by  an 
iridectomy.  I  have  always  retained  the  same  site  for 
simple  as  for  combined  extraction.  Much  of  the  tendency 
to  prolapse  through  a  large  sclero-corneal  wound  may  be 
overcome  by  the  early  adhesion  of  a  fairly  complete  con- 
junctival flap.  And  we  have  in  general  been  more  careful 
to  provide  an  effective  conjunctival  covering  than  in  com- 
bined extraction.  Perhaps  a  more  effectual  additional  safe- 
guard is  the  combination  of  eserin  and  adrenalin  instillation. 
And  perhaps  with  this  posterior  incision  one  must  be 
more  ready  to  perform  iridectomy  at  the  close  of  the 
operation,  should  the  pupil  be  at  all  distorted  and  dis- 
placed. In  Bombay  we  would  have  given  up  simple 
extraction  altogether  if  its  performance,  by  altering  the 
site  of  the  incision,  had  necessitated  giving  up  or  con- 
siderably reducing  the  conjunctival  flap.  The  conjunctival 
covering  was  considered  a  necessity,  and  the  retention  of 
the  intact  iris  rather  a  luxury. 

Should  the  iris  have  been  much  scraped  by  the  knife,  or 
should  a  small  piece  of  it  have  been  unintentionally  excised,  it 
is  better,  as  a  rule,  to  complete  the  iridectomy  at  once  before 

15 


2  26  Cataract  Extraction 

delivering  the  lens.  Otherwise  the  margin  of  the  lens,  instead 
of  coming  forward  to  the  pupil,  tends  to  engage  in  the  weakened 
area  of  iris.  The  intact  pupillary  band  holds  the  lens  back 
until  the  band  becomes  much  stretched  or  broken. 

Should  iris  prolapse  immediately  after  the  section  has  been 
made,  it  is  replaced  by  the  curette.  If  a  round  pupil  is  not 
secured  at  once,  it  is  perhaps  well  to  perform  iridectomy. 

In  performing  the  capsulotomy  long  incisions  are  not 
quite  so  readily  made  as  when  there  is  a  coloboma,  hence 
they  more  generally  need  to  be  multiple.  The  use  of 
capsule  forceps  is  described  later. 

Delivery  of  the  Lens  and  of  Cortical  Remains. -^Ste-dAy 
continuous  pressure  is  applied  with  the  hook  or  spoon 
directly  backwards  about  the  junction  of  the  middle 
and  lower  fourths  of  the  cornea,  while  counter-pressure  is 
made  with  the  curette  placed  horizontally  above  the  wound. 
The  hook  is  held  in  the  right  hand  and  the  curette*  in  the 
left  hand.  The  primary  object  is  to  tilt  the  upper  edge  of 
the  lens  forward  into  the  pupil.  The  corneal  flap,  if  its 
base  be  sufficiently  low,  at  once  swings  forward,  and  with 
it  the  lens  and  upper  part  of  the  iris.  At  the  same  time 
some  little  upward  movement  of  the  lens  and  of  its  cover- 
ing iris  takes  place.  The  iris  stretches,  but  less  so  than 
the  pupil,  which  widens  mostly  laterally  as  the  lens 
equator  slowly  revolves  forward  to  occupy  it.  As  soon  as 
the  upper  margin  of  the  lens  is  visible  at  the  upper  border 
of  the  pupil  a  slight  increase  of  the  pressure  of  the  hook 
backwards  and  upwards  suffices  to  bring  the  lens  forward 
into  the  chamber  and  into  the  gaping  wound.  The  back- 
ward pressure  of  the  curette  assists  in  drawing  the  iris 
back  over  the  upper  margin  of  the  lens.     As  soon  as  this 

*  For  use  upon  the  right  eye  the  curette  held  in  the  left  hand  must 
be  fully  curved,  otherwise  it  cannot  be  laid  flat  above  the  wound.  If 
the  curette  be  made  of  German  silver,  the  curve  maybe  readily  altered 
as  desired. 


Variations  in  Procedure,  and  their  Value     227 

upper  part  of  the  iris  has  receded  behind  the  presenting 
lens,  the  steady  pressure  upon  the  cornea  may  often  be 
advantageously  replaced  by  repeated  short,  light,  upward 
pushing  strokes  over  the  lower  part  of  the  cornea. 

These  strokes  are  very  effective  applied  below  the  lower 
margin  of  a  firm  discoid  lens.  The  lens  should  thus  pass 
upwards  without  carrying  the  iris  into  the  wound,  so  that 
when  the  lens  is  delivered  the  wound  may  close  unoccupied 
by  iris.  Cataracts  with  firm  cortex,  however,  and  flattened 
.anterior  surface  and  sharp  equator,  do  not  come  forward 
easily  into  the  pupil,  and  upon  continued  pressure  readily 
slip  upwards  and  carry  the  iris  into  the  wound.  The  same 
trouble  frequently  occurs  with  too  small  a  section,  i.e., 
with  a  section  suited  for  most  combined  extractions.  If 
the  pressure  be  continued,  the  sharp  edge  of  the  lens 
stretches  the  iris  considerably,  scraping  off  uveal  pigment 
and  weakening  the  sphincter  muscle,  before  finally  enter- 
ing the  pupil,*  so  that  it  is  better  to  relinquish  for  the 
moment  the  attempt  to  express  the  lens.  The  curette 
having  been  removed  and  the  wound  allowed  to  close,  the 
lens  is  pushed  downwards  into  position  by  the  convexity 
of  the  hook  (or  spoon)  applied  to  the  upper  part  of  the 
cornea.  A  second  attempt  to  swing  the  lens  equator  for- 
ward into  the  pupil  may  be  then  more  successful.  In 
general,  quicker  expression  is  aimed  at  than  in  combined 
extraction,  since  only  fairly  ripe  cataracts  are  operated 
upon  without  iridectomy.  A  rather  rapid  passage  of  the 
lens  through  the  pupil  obviates  unnecessarily  prolonged 
stretching  of  the  sphincter,  and  so  tends  to  reduce  the 
risk  of  subsequent  prolapse. 

In  cataracts  with  much  soft  cortex,  the  nuclei  and  the 

*  The  iris  might  be  drawn  back  over  the  presenting  edge  of  the 
lens  by  the  curette  moved  downwards  into  contact  with  the  iris,  were 
it  not  for  the  danger  of  transferring  conjunctival  organisms  thus  into 
the  wound. 

15—2 


2  28  Cataract  Extraction 

greater  part  of  the  broken-up  cortex  slip  forward  easily 
through  the  pupil  without  undue  stretching  of  the  iris. 
But  some  lens  substance  remains,  especially  behind  the 
upper  part  of  the  iris,  to  be  dislodged  by  external  pressure 
alternated  with  irrigation,  as  described  in  the  combined 
operation.  Cortex  behind  the  upper  iris  may  often  be 
displaced  downwards  into  the  pupillary  area  by  pressure 
with  the  hook  or  other  instrument  upon  the  cornea  just 
below  the  wound,  while  pressure  is  also  maintained  with  the 
curette  upon  the  sclerotic  above.  Also,  while  irrigating,  a 
touch  with  the  point  of  the  nozzle  upon  the  iris  is  often 
useful  in  expelling  lens  matter  lodged  behind  the  iris.  It 
is  only  to  be  expected  that  the  douche  must  prove  less 
effective  in  removing  cortex  when  the  iris  is  intact  than 
when  there  is  a  coloboma  ;  and  if  a  strong  current  be 
directed  into  the  posterior  chamber  (except  with  the  double- 
current  syringe)  the  iris  is  apt  to  be  carried  by  it  into 
the  wound.  After  clearing  away  all  the  visible  lens  sub- 
stance it  may  be  taken,  as  a  general  rule,  that  a  wholly  black 
pupil  is  a  sufficient  guarantee  that  any  peripheral  cortex 
still  remaining  hidden  behind  the  iris  is  in  such  small 
quantity  that  it  may  be  safely  left.  One  often  prefers  to 
leave  a  small  quantity  of  refractory  soft  cortex  rather  than 
to  perform  an  iridectomy  to  aid  in  its  removal.  But  an 
iridectomy  must  sometimes  be  made  on  this  account. 

Replacement  of  Iris. — There  is  reason  for  satisfaction 
when  the  pupil  spontaneously  resumes  its  normal  shape, 
size,  and  position,  after  the  evacuation  of  the  lens  matter. 
More  often  the  pupil  is  more  or  less  displaced  upwards 
and  perhaps  distorted  and  enlarged.  A  light  touch  with 
curette  or  spatula  introduced  into  the  chamber  may 
effectually  replace  the  iris.  Or  light  massage  upon  the 
centre  of  the  cornea  with  the  back  of  the  curette  or  of  a 
tortoiseshell  spoon  may  induce   sufficient  contraction  of 


Variations  in  Procedure,  and  their  Value    229 

the  sphincter  muscle.  Occasionally  it  may  be  permissible 
to  draw  the  iris  into  position  with  iris  forceps  passed  into 
the  chamber,  though  I  have  never  practised  this  means  of 
replacement. 

De  Wecker  and  others  have  recommended  irrigation 
especially  as  a  means  of  replacing  iris  at  the  close  of  the 
operation  instead  of  using  the  curette  or  repositor,  when- 
ever the  pupil  is  displaced  and  distorted,  still  more  when 
the  iris  lies  incarcerated  or  prolapsed  in  the  wound.  He 
and  Hofmann  introduced  eserin  solution,  ^  to  ^^  per  cent., 
into  the  anterior  chamber  with  this  object.  Elliot* 
(Madras)  describes  replacement  thus  : 

"  The  current  is  directed  first  under  the  lower  margin  of  the 
iris,  then  on  the  lips  of  the  wound  from  above,  and  finally,  if 
necessary,  over  the  anterior  surface  of  the  iris,  the  nozzle  being 
inserted  in  the  chamber. . . .  Where  iris  is  retained  in  the  wound 
by  cheesy  cortex  impacted  behind  the  scleral  lip  of  the  wound, 
the  lens  matter  is  dislodged  by  a  stream  of  fluid  directed  back- 
wards, or  even  backwards  and  upwards.  If  this  fails,  a  portion 
of  the  lens  capsule,  seen  hanging  down  into  the  chamber,  is 
seized  with  iris  forceps  and  drawn  towards  the  centre  of  the 
pupil.  The  upper  cul-de-sac  of  capsule  is  thus  everted  and 
emptied  of  its  contents  into  the  chamber." 

The  pupil,  in  spite  of  these  efforts,  may  still  remain  dis- 
placed a  little  upwards  and  either  vertically  elongated, 
perhaps  pear-shaped,  with  the  apex  upwards,  or  simply 
enlarged.  This  shows  an  injured  iris  and  a  consequent 
liability  to  prolapse.  The  same  may  be  shown  simply  by 
a  quite  inert  sphincter  muscle.  The  pupil  can  perhaps  be 
pushed  into  the  normal  shape  and  position  without  much 
dilatation,  but  there  is  no  tendency  to  spontaneous 
resumption  and  no  active  retention  of  this  normal 
form,  the  pupil  simply  remaining  in  any  shape  imparted 

to  it. 

*  Ind.  Med.  Gazette^  xii  (1906),  203. 


230  Cataract  Extraction 

In  our  work  we  attributed  many  of  our  injured  irises  and 
consequent  prolapses  to  the  use  of  knives  with  slightly  dulled 
edges.  Hence  rather  slow  incision,  sufficient  of  it  not  being 
completed  before  all  the  aqueous  had  escaped,  bringing  the  iris 
into  contact  with  the  blade.  We  noticed  also  that  this  injury 
of  the  iris  with  the  knife  occurred  more  often  in  the  left  eye, 
owing  to  the  laboured  incision  made  with  the  less  expert  left 
hand.  Another  cause,  unrecognized  in  our  earlier  practice, 
was  the  making  of  too  small  a  section,  embracing  two-fifths 
or  less  of  the  corneal  circumference.  Hence  the  lens  had  to 
move  upwards  a  little  behind  the  iris  before  it  could  rotate 
fully. 

The  more  marked  defects  necessitate  immediate  iridec- 
tomy ;  the  slighter  grades  may  often  be  overcome  by  the  in- 
stillation of  eserin,  especially  if  adrenalin  has  been  used 
before  the  operation.  A  simple  instillation  of  eserin,  4  grains 
to  the  ounce,  is  perhaps  advisable  as  a  routine  practice  after 
all  simple  extractions.  But  when  there  is  any  particular 
occasion  to  fear  prolapse  three  instillations  should  be  made 
at  intervals  of  a  minute,  several  drops  being  used  each 
time  to  flush  out  the  conjunctival  sac.  The  comparative 
ineffectiveness  of  a  single  instillation,  and  the  need  for  its 
repetition  thus  immediately  after  operation,  are  due  to  the 
washing  away  of  the  solution  by  tears  and  probably  by 
aqueous.  If  the  closed  lids  are  watched  after  the  instilla- 
tion, fluid  slightly  tinted  by  the  eserin  may  often  be  seen 
to  ooze  out  and  to  flow  away  from  the  outer  canthus. 

Though  eserin  is  by  no  means  so  sure  a  preventive  of 
prolapse  as  iridectomy,  yet  one  may  decide  to  give  it  a 
trial,  because  iridectomy  at  the  close  of  a  cataract  opera- 
tion  is   neither   easy  of  performance  nor   a   very   safe* 

*  Yet  de  Wecker  [Ann.  cfOcuL,  xciv  (1885),  41]  recommended  the 
routine  performance  of  iridectomy  at  this  stage,  because  of  the 
difficulty  sometimes  experienced  in  determining  earlier  whether  the 
consistence  and  size  of  the  lens  were  such  as  to  necessitate  an  excision 
of  iris. 


Variations  in  Procedure,  and  their  Value    231 

proceeding.  The  patient  may  have  now  *  lost  his  nerve ' 
and  be  unable  to  keep  the  eye  still,  and  fixation  with 
forceps  is  practicable  even  less  than  before  the  lens  was 
removed.  The  lens  when  present  affords  some  support  to 
the  suspensory  ligament  and  posterior  capsule.  Thus  the 
performance  of  the  iridectomy  may  possibly  lead  to  a  loss 
of  vitreous. 

Some  operators — e.g.,  Haab  and  Pagenstecher — prefer 
to  perform  iridectomy  whenever  the  iris  does  not  return 
readily  into  position  after  delivery  of  the  lens.  It  has 
been  remarked  that  if  a  flaccid  iris  be  met  with  in 
operating  upon  one  eye  of  a  patient,  it  will  also  be  found 
in  the  fellow  eye. 

It  is  not  essential  that  the  iridectomy  shall  be  complete. 
A  simple  '  buttonhole '  is  probably  quite  effective  (see 
below),  leaving  the  pupillary  zone  of  iris  untouched.  But 
this  partial  excision  is  more  difficult  to  accomplish,  par- 
ticularly because  the  portion  of  iris  concerned  is  generally 
narrowed  by  the  upward  displacement  of  the  pupil.  It 
may  be  attempted,  though  sometimes  the  attempt  will 
result  in  a  complete  coloboma. 

Rather  greater  care  being  demanded  in  the  after-treat- 
ment of  simple  extraction,  both  eyes  are  kept  covered  for 
a  day.  After  this  it  is  usually  sufficient  to  keep  one  eye 
bandaged  only.  The  patient  must  be  kept  as  quiet  as 
possible,  and  he  should  be  made  to  sleep  well  the  first 
night. 

Among  other  means  which  have  been  found  useful  for 
the  prevention  of  prolapse  may  be  mentioned  : 

1.  Sedatives  and  soporifics — morphia  injections,  bro- 
mides, etc.,  before  operation. 

2.  Suture  of  the  wound  or  of  the  conjunctival  flap ; 


232  Cataract  Extraction 

the  subconjunctival  operations ;  also  covering  the  wound 
with  a  bridge  of  conjunctiva  (Kuhnt). 

Von  Millingen  suggested  corneal  contact  glasses  applied 
for  the  day  following  operation. 


PERIPHERAL  IRIDECTOMY  AND   IRIDOTOMY. 

Bell  Taylor*  practised  cataract  extraction  through  an  open- 
ing in  the  iris  at  its  base,  in  order  to  leave  the  pupil  quite 
untouched,  and  so  to  guard  against  prolapse  and  impaction  of 
the  iris  in  the  wound.  He  made  a  small  peripheral  iridectomy, 
and  then  enlarged  the  opening  by  a  transverse  cut  on  each  side 
with  fine  scissors.  The  chief  drawbacks  to  the  method  were 
the  rather  complicated  procedure,  difficulty  in  delivering  the 
lens  through  the  opening,  and  distortion  of  the  pupil  after- 
wards, from  the  wide  separation  of  the  root  of  the  iris. 

I  made  use  of  a  basal  opening  in  the  iris,  in  ten  cases  of 
Morgagnian  cataract  only,  for  the  expulsion  of  the  nucleus. 
Though  only  a  comparatively  small  opening  was  needed,  vary- 
ing with  the  size  of  the  nucleus,  the  making  of  it  generally 
required  two  snips  with  the  scissors,  the  iris  having  to  be 
drawn  out  of  the  wound  twice  for  this  purpose.  The  method 
was  abandoned  because  it  introduced  an  impediment  to  the 
subsequent  dilatation  of  the  pupil  by  the  loss  of  the  dilator 
fibres  of  the  iris  over  a  fairly  wide  area,  and  dilatation  of  the 
pupil  was  somewhat  frequently  called  for  in  these  cases  on 
account  of  muddiness  of  the  pupil  and  iris.  The  cases  were 
too  few  in  number  to  enable  one  to  judge  whether  this  early 
exudation  was  attributable  to  bruising  of  the  iris,  with  some 
interference  with  the  circulation  in  the  bridge  of  tissue  left. 
This  bridge,  in  particular,  tended  to  become  bound  down  early 
by  adhesions.  A  minor  advantage  of  this  operation  for 
Morgagnian  cataract  lay  in  the  fact  that  only  a  very  small 
section  was  needed,  just  as  for  ordinary  combined  extraction  of 
these  lenses. 

Bajardif  makes  a  considerable  peripheral  incision  in  the  iris, 
through  which  he  expels  the  whole  of  the  lens  cortex.    The  base 

*  The  Lancet^  1871,  vol.  ii,  pp.  634  and  802. 
t  La  Clinica  Octiltstica,  Aprile-Luglio,  1905. 


Variations  in  Procedure,  and  their  Value    233 

of  the  iris  is  punctured  by  de  Wecker's  blunt-pointed  scissors 
immediately  after  the  corneal  section  has  been  made,  and  the 
opening  is  enlarged  after  the  nucleus  of  the  lens  has  been 
delivered  through  the  pupil.  Pfliiger*  and  Hess  have  made  a 
small  basal  iridectomy  merely  to  prevent  prolapse,  after  deliver- 
ing the  lens  and  cortex  through  the  pupil.  Whether  this 
practice  be  confined  or  not  to  cases  where  attempted  simple 
extraction  has  led  to  weakening  of  the  sphincter  and  distortion 
of  the  pupil  (see  above),  the  small  peripheral  opening  appears 
preferable  to  the  complete  coloboma  of  ordinary  combined  ex- 
traction. A  sufficient  '  sluice  gate  '  is  provided  for  the  passage 
of  fluid  from  the  posterior  chamber,  and  there  are  not  the 
drawbacks  of  the  wider  basal  iridectomy  already  mentioned. 
The  shape  of  the  pupil  is  unaffected.  The  small  opening  is 
frequently  covered  by  the  upper  lid.  And  the  pupillary  bridge 
of  iris,  if  it  retains  or  quickly  regains  its  tone,  may  aid  in 
preventing  prolapse. 

Beckles  Chandler,!  operating  with  a  basal  iridectomy,  got 
four  prolapses  in  312  extractions;  two  of  the  accidents  were 
due  to  direct  violence. 

Elliot:]:  (Madras)  gave  peripheral  excision  of  iris  a  trial, 
practised  before  delivery  of  the  lens.  As  is  well  known,  delivery 
of  the  lens  through  the  pupil  is  rendered  difficult  by  the 
presence  of  such  an  artificial  opening  in  the  iris.  Elliot  found 
the  removal  of  cortex  by  irrigation  much  less  easy  than  with  a 
complete  coloboma. 

Schweigger,§  practising  a  downward  section,  has  utilized  a 
basal  iridotomy  to  prevent  prolapse.  After  introducing  tropo- 
cocain  into  the  anterior  chamber  to  obtain  complete  anaesthesia, 
he  pulls  the  iris  forward  with  fine  forceps  and  makes  an 
extensive  peripheral  incision  with  a  broad  needle.  Eserin  is 
then  instilled,  to  widen  the  opening  by  contraction  of  the  pupil. 
The  incision  generally  closes  completely  later. 

VerhoefFII  (Boston),  extends  the  principle  of  the  key-hole 
iridectomy  into  a  combined  iridectomy  and  iridotomy.  After 
making  a  small  peripheral  buttonhole,  he  incises  the  iris  from 

*  XII  Congr.  Intern,  de  Med.  a  Moscou  (1898). 

t  Arch,  of  Ophth..,  xxxiii  (1904),  i. 

%  Ind.  Med.  Gazette,  xli  (1906),  203. 

§  Arch,  of  Ophth.,  xxvii  (1898),  255. 

li  Ref.  ^r^,^.  ^C/^///.,  XXXV  (1906),  453. 


234  Cataract  Extraction 

the  opening  to  the  pupil  with  scissors.  "  The  excision  of  iris 
tissue  is  made  where  it  will  be  most  effective  in  preventing  iris 
prolapse,  and  at  the  same  time  do  the  least  damage  from  an 
optical  standpoint.  .  .  ."  "The  lens  is  removed  with  the  same 
ease  as  in  the  combined  operation,  and  cortical  matter  is  readily 
expressed." 

A  vertical  iritomy,  or  '  sphincterotomy,'  is  made  by  Mano- 
lescu,  Pascheff,  and  Mark  Stevenson  (Akron).  Pascheff* 
does  this  with  an  "  iridotome,"  consisting  essentially  of  a  hook 
to  engage  the  sphincter  within  the  chamber,  and  a  small  knife 
sliding  upon  the  hook. 

PRELIMINARY  IRIDECTOMY. 

Preliminary  or  preparatory  iridectomy,  a  few  weeks! 
before  extraction  of  the  lens,  was  practised  first  by  von 
Graefe.  The  double  operation  was  found  to  be  somewhat 
safer  than  any  form  of  single  operation,  and  only  the 
inconvenience  of  the  prolonged  or  repeated  treatment 
restricted  its  application.  This  inconvenience,  especially 
now  that  a  secondary  operation  for  after-cataract  is  so 
frequently  performed,  is  certainly  weighty.  The  value  of 
the  method,  as  compared  with  the  ordinary  combined 
operation,  depended  upon  a  reduction  in  the  number  of 
infections,!  and  of  prolapses  and  incarcerations  of  iris 
observed  after  operation. 

In  practice  it  is  not  true  that  the  double  operation 
introduces  two  chances  of  infecting  the  eye.  For  the 
iridectomy  operation,  even  in  pre-antiseptic  days,  was 
almost   free   from   infective  risk,  and   now  is  practically 

*   Wochens.f.  Ther.  w.  Hygiene  des  Anges,  Marz  9,  1905. 

t  The  interval  between  iridectomy  and  extraction  has  varied  from 
a  few  days  to  eight  weeks. 

:|:  The  Moorfiekls  records  from  1889-93,  however,  do  not  show  any 
marked  difference  in  the  proportion  of  suppurations — 1*58  per  cent, 
after  extraction  with  preliminary  iridectomy;  172  per  cent,  after  the 
combined  operation  ;  178  per  cent,  after  simple  extraction  (Marshall, 
R.  L.  0.  H.  Rep.,  xiv,  56). 


Variations  in  Procedure,  and  their  Value     235 

entirely  so.  The  succeeding  extraction  proved  to  be  less 
dangerous  than  an  ordinary  combined  operation,  owing 
probably  to  the  shortening  and  simplification  of  the 
operation.  Involvement  of  the  iris  in  the  wound  after  the 
operation  has  been  certainly  rare. 

A  minor  advantage  claimed  is  that  the  extraction  is  not 
so  likely  to  be  complicated  by  bleeding,  provided  sufficient 
time  has  elapsed  for  the  scar  of  the  iridectomy  wound  to 
become  only  feebly  vascular  (and  provided  the  second 
incision  follows  the  same  line  as  the  first.  In  England, 
however,  the  iridectomy  incision  is  usually  placed  an- 
teriorly to  the  cataract  section).  The  preliminary  opera- 
tion is  also  said  to  have  a  valuable  educational  effect  upon 
the  patient,  and  to  enable  the  operator  to  judge  of  the 
behaviour  to  be  expected  during  the  major  operation. 

Improvement  in  technique  and  a  better  understanding 
of  the  origin  of  infective  troubles  and  of  prolapse  of  iris 
have  practically  abolished  the  need  for  this  division  of  the 
operation  for  ordinary  ripe  cataracts.  In  some  compli- 
cated cataracts,  however,  the  iridectomy  as  a  separate 
operation  may  be  desirable  to  show  the  condition  of  the 
lens  or  to  reduce  tension.  It  is  performed  also  in  cases 
where  one  eye  has  been  lost  from  profuse  haemorrhage 
following  cataract  extraction.  And  in  dealing  with  unripe 
cataracts  preliminary  iridectomy  has  to-day  a  considerable 
vogue  as  part  of  Forster's  ripening  procedure.  As  already 
mentioned,  a  few  operators  practise  the  iridectomy  alone, 
without  massage  of  the  lens,  as  a  ripening  measure. 

Hirschberg*  laid  down  preliminary  iridectomy  as  necessary 
where  there  was  high  tension,  lest,  as  pointed  out  by  Arlt, 
extraction  should  give  rise  to  expulsive  haemorrhage ;  and  also 
in  eyes  after  sympathetic  ophthalmia.  He  considered  it 
advantageous  for  annular  or  multiple  broad  posterior  synechiae ; 
also  where  there  was  only  the  one  eye,  or  where  any  mental  or 

*  D.  Zeitschr.f.pr.  Med.,  1874,  S.  31. 


236  Cataract  Extraction 

general  condition  appeared  likely  to  interfere  with  rest  after- 
wards ;  and,  finally,  for  Forster's  ripening. 

Kuhnt  practises  preparatory  iridectomy  where  there  is 
diabetes,  gout,  or  chronic  rheumatism,  posterior  synechige, 
recent  cyclitis,  anaesthesia  of  cornea  or  suspected  glaucoma, 
and  in  persons  of  anxious  temperament;  Critchett,  when  trouble 
from  much  soft  cortex  is  anticipated ;  True,  in  indocile  subjects. 

OTHER  MODES  OF  OPENING   THE  CAPSULE. 

Peripheral  Capsulotomy. — The  opening  of  the  capsule 
in  the  upper  periphery  stands  in  direct  contrast  to  the  removal 
of  a  portion  of  the  capsule.  It  leaves  the  whole  of  the  pupillary 
area  occupied  by  the  two  layers  of  capsule. 

It  was  introduced  by  Gayet*  to  avoid  the  drawbacks 
experienced  from  tags  of  capsule  left  in  the  pupillary  area.  He 
practised  combined  extraction,  and  divided  the  capsule  at  the 
equator  of  the  lens  after  causing  the  latter  to  tilt  forward  into 
the  wound  by  exerting  backward  pressure  at  or  below  the 
middle  of  the  cornea. 

Quioct  recommended  a  broad  iridectomy,  and  divided  the 
capsule  with  a  Graefe's  knife  along  the  whole  length  of  the 
wound.  He  considered  the  procedure  applicable  to  lenses  with 
softened  cortex,  and  especially  to  Morgagnian  cataracts.  From 
these  latter  the  nucleus  escapes  much  more  readily  through  an 
upper  opening  than  through  a  central  one. 

Knapp  still  uses  "peripheric  splitting"  systematically  for  all 
forms  of  cataract,  and  without  iridectomy. 

He  thus  describes  J  the  procedure :  "  The  operator  gives  the 
knife  back  to  the  assistant,  and  takes  from  him  a  cystitome, 
which  he  introduces  into  the  anterior  chamber,  with  the  knee 
forward,  from  the  temporal  side,  near  the  conjunctival  flap, 
which  latter  he  is  careful  not  to  drag  into  the  eye.  He  then 
advances  the  instrument  so  that  the  tip  goes  underneath  the 
upper  part  of  the  iris,  turns  it,  and  with  the  tooth  makes  the 
incision  into  the  upper  part  of  the  capsule,  parallel  with  the 
corneal  section,  about  6  or  7  millimetres  in  extent.  As  soon 
as  the  capsule  is  opened  the   lens  makes  a   visible  forward 

*  Gaz.  hebd.,  Nr.  35,  1873. 

t   These  de  Paris,  1879. 

X  Norris  and  Oliver's  '  System,'  iii,  798. 


Variations  in  Procedure^  and  their  Value     237 

motion ;  then  the  cystitome  is  withdrawn  again  with  the  knee 
forward,  so  that  the  point  does  not  injure  the  iris." 

The  particular  advantage  is  that  there  are  no  shreds  of 
capsule  to  unite  with  the  lacerated  pupillary  margin,  and  so 
the  pupil  remains  free  from  posterior  synechise.  The  lens 
escapes  easily,  and  entanglement  of  tags  of  capsule  in  the 
wound  cannot  take  place,  though,  if  an  iridectomy  be  made, 
there  may  be  adhesion  between  the  capsular  and  corneal 
incisions.  Cortical  remains  become  enclosed  by  early  union  of 
the  capsular  incision.  Thus  irritation  of  the  iris  is  avoided, 
but  the  cortex  is  only  slowly  and  imperfectly  absorbed.  The 
drawback  to  the  method,  which  has  prevented  its  general 
adoption,  is  the  necessity  for  an  after-operation  in  a  very  large 
proportion  of  cases  to  give  permanently  clear  vision.  Rarely, 
the  entrance  of  blood*  into  the  capsule  may  give  trouble,  owing 
to  slow  resorption. 

Opening  of  the  Capsule  at  the  time  of  the  Corneal 
Section  (Keratokystitomie  of  Gayet). — It  is  a  very  old 
practice  to  incise  the  capsule  with  the  point  of  the  knife  as  it 
passes  across  the  anterior  chamber.  Gayet  f  first  utilized  the 
method  on  a  large  scale.  Many  others  have  reported  favour- 
ably and  unfavourably  upon  it,  and  it  is  still  employed  to  a 
small  extent.  Gayet  dipped  the  point  of  the  knife  a  little  way 
under  the  capsule  at  the  middle  of  the  pupil  to  either  raise  a 
flap  of  the  membrane  or  simply  to  tear  it.  Some  operators 
have  preferred  to  extend  the  puncture  vertically.  But  much 
movement  of  the  blade  tends  to  slight  distortion  of  the  wound 
surfaces  and  to  premature  escape  of  aqueous  and  its  conse- 
quences. Some  surgeons  have  been  satisfied  with  a  small 
puncture,  withdrawing  the  blade  sufficiently  to  free  the  point, 
and  trusting  to  the  pressure  of  the  lens  during  delivery  to 
enlarge  the  opening.  The  opening  is  apt  to  be  insufficient 
except  in  somewhat  unripe  cataracts,  for  in  fully  ripe  and 
slightly  overripes  cataracts  the  capsule  may  prove  to  be 
toughened,  though  not  noticeably  opaque.  Knapp  held  the 
method  inapplicable  for  thickened  capsules,  also  where  the 
pupil  was  small  or  the  anterior  chamber  shallow. 

There  appears  to  be  some  slight  risk  of  pressing  the  lens 

*  Chisholm,  Report  on  the  Eye  and  Ear  Infirmary,  Baltimore, 
1879- 
t  Ann.  d'Ocul.,  xcv  (i886),  227. 


238  Cataract  Extraction 

backwards  in  penetrating  a  thickened  capsule,  or  even  of  dis- 
locating the  lens  forward  into  the  anterior  chamber  (Pfluger) 
after  transfixing  the  membrane. 

To  compensate  for  these  disadvantages  there  is  only  the 
simplification  of  the  operation — the  combination  of  two  stages 
into  one — and  the  elimination  of  an  instrument. 

Preliminary  Capsulotomy. — The  opening  of  the  capsule 
by  means  of  a  fine  (Bowman's)  needle  before  making  the 
section  has  been  adopted  by  a  few  operators.  It  has  formed 
the  routine  practice  in  the  Madras  hospital. 

Haab  has  occasionally  employed  the  method  in  juvenile 
cataracts.  It  is  claimed  that  useful  information  is  thus 
obtained  as  to  the  size  of  the  nucleus  and  the  consistence  of 
the  cortex ;  also  that  the  capsular  opening  is  made  more 
exactly,  since  the  operator  can  see  better  what  he  is  doing,  and 
the  point  of  the  needle  cannot  be  hidden  by  blood,  as  it  may  be 
after  the  section  is  made.  Also  the  pupil  is  wider  (dilated  with 
atropin)  than  after  the  emptying  of  the  anterior  chamber.  The 
needle  is  inserted  at  the  limbus  to  obviate  escape  of  aqueous. 
Should  any  fluid  escape,  it  suffices  to  wait  a  few  minutes  for  its 
re-accumulation. 


The  Extraction  of  Anterior  Capsule. 

Until  1874,  when  Forster  began  the  systematic  removal 
of  a  portion  of  the  transparent  anterior  capsule,  the  pro- 
cedure had  been  almost  entirely  confined  to  opaque 
thickened  capsules.  It  is  now  preferred  to  all  forms  of 
capsulotomy,  whenever  applicable,  by  numbers  of  ex- 
perienced operators.  It  certainly  fulfils  the  indications 
(p.  100)  better.  It  is  practised  both  with  and  without 
iridectomy.  The  coloboma  is  a  convenience  in  that  it 
eliminates  the  risk  of  nipping  the  iris  together  with  the 
capsule,  and  permits  of  forceps  being  used  with  numerous 
teeth  to  afford  an  extended  grip  of  the  membrane.  But 
apparently  the  smaller  hold  taken  with  the  iris  intact 
very  frequently  suffices  for  the  tearing  away  of  the  greater 
part  of  the  anterior  capsule.     The  rupture  tends  to  take 


Variations  in  Procedure,  and  their  Value    239 

place  near  the  equator,  because  the  capsule  is  thinner  there 
than  about  the  pole  of  the  lens. 

The  patient  must  look  downwards,  and  the  globe  is 
fixed  below.  Any  blood  present  in  the  anterior  chamber 
is  expressed  or  washed  out  as  fully  as  possible.  The 
forceps  are  introduced  at  the  summit  of  the  wound  with 
the  blades  closed  and  directed  straight  downwards.  They 
are  passed  down  almost  to  the  lower  border  of  the  pupil  and 
then  slowly  opened  so  that  the  blades  reach  to  the  lateral 
borders  of  the  pupil.  The  pupil  may  be  a  little  widened 
horizontally  by  the  forceps  to  allow  of  a  larger  hold  of  the 
capsule  being  taken.  The  ends  are  then  pressed  back- 
wards lightly  on  to  the  lens  and  closed. 

The  next  movement  of  the  closed  forceps,  presumably 
gripping  a  fold  of  capsule,  is  downwards.  The  capsule  is 
thus  torn  above,  generally  near  the  equator  of  the  lens, 
and  in  simple  extraction  one  can  see  that  the  iris  is  free. 
Then  with  slow  side-to-side  movement  the  instrument  is 
withdrawn.  In  combined  extraction,  if  the  capsule  be  not 
first  torn  above,  it  is  liable  to  be  drawn  into  the  wound 
and  to  tear  beyond  the  wound,  leaving  a  tongue  of  the 
membrane  impacted. 

Should  the  forceps  have  failed  to  seize  the  capsule,  or 
should  the  iris  have  been  nipped,  the  manoeuvre  of  opening 
and  closing  the  instrument  is  repeated  with  the  ends 
directed  at  an  increased  angle  to  the  lens.  Increasing  the 
angle  necessitates  some  pushing  forward  of  the  corneal  flap, 
opening  the  wound  more. 

It  is  difficult  to  grasp  the  tense  capsule  of  a  swollen 
lens.  In  cataracts  with  soft  or  fluid  cortex  the  teeth  often 
glide  over  the  surface  instead  of  gripping  it,  or  they  may 
pierce  the  capsule  and  tear  it  irregularly.  The  forceps  may 
then  come  away  at  once,  bringing  with  them  little  or  no 
capsule.     Or,    especially   in   the   case   of   a   Morgagnian 


240  Cataract  Extraction 

cataract  with  thickened  capsule,  they  may  tear  away  a 
portion  of  the  membrane ;  but  only  after  a  pull  sufficient 
to  rupture  the  suspensory  ligament  below.  It  is  con- 
sidered expedient  to  open  all  tense  capsules  first  with  the 
cystitome  or  sharp  hook.  But  here  we  tend  to  needless 
elaboration,  since  the  use  of  the  cystitome  or  hook  alone 
may  amply  suffice.  Terson*  (pere)  makes  a  small  opening 
with  a  cystitome  below  in  all  opaque  capsules  before  using 
the  forceps,  much  as  described  on  p.  112.  It  is  in  general 
unwise  to  prolong  the  stage  of  the  operation  unnecessarily, 
lest  the  patient's  stock  of  self-command  be  thus  early  ex- 
hausted. Provided  the  capsule  is  not  definitely  thickened 
and  opaque,  the  use  of  the  forceps  succeeds  best  in 
lenses  with  firm  cortex,  that  is,  when  the  lens  is  flattened 
and  reduced  in  bulk  from  the  normal.  With  an  opaque 
capsule  there  is  some  risk  of  tearing  both  zonule  and 
capsule  simultaneously,  or  zonule  alone,  unless  the  cysti- 
tome be  used  first. 

If  the  pupil  be  small  and  rigid,  the  use  of  capsule  forceps 
is  contra-indicated,  unless  with  a  wide  iridectomy.  The 
patient  must  be  reliable  and  quiet,  and  the  fixity  of  the 
eye  must  be  assured  before  one  should  venture  upon  pro- 
longed retention  of  an  instrument  pointing  directly  down- 
wards far  within  the  chamber. 

Forster  and  de  Wecker  have  found  that  the  piece  of 
capsule  removed  has  frequently  measured  6  or  7  milli- 
metres across,  and  has  therefore  included  nearly  the  whole 
of  the  anterior  capsule,  which  measures  only  about  g  milli- 
metres. Thus  the  freest  exit  is  secured  for  the  lens. 
Also  the  chances  of  capsular  shreds  becoming  entangled  in 
the  wound,  and  of  adhesions  forming  between  the  margins 
of  the  capsular  and  pupillary  openings,  are  reduced  to  a 
minimum.     These,  however,  can  be  counted  only  as  minor 

*  Aftn.  d'OcuLj  cxxxix  (1903),  420. 


Variations  in  Procedure,  and  their  Value     241 

benefits,  for  both  of  these  compHcations  can  be  usually 
avoided  without  removing  capsule.  And  a  few  fine  pos- 
terior synechiae  are  not  of  great  consequence.  The  main 
advantage  of  partial  capsular  extraction  may  be  summed 
up  in  the  fact  that  it  largely  reduces  the  number  of  need- 
lings  required  for  after-cataract.  Enclosure  of  lenticular 
remains  is  practically  impossible,  and  later  capsular  pro- 
liferations and  foldings  can  seldom  take  place.  Treacher 
Collins*  reported  that  in  a  series  of  a  hundred  extractions 
using  the  capsular  forceps,  only  four  eyes  required  sub- 
sequent needling.  He  found  that  25  per  cent,  of  his  cases 
got  full  vision  (f)  with  only  the  single  operation. 

Considering  that  early  discission  for  the  purely  capsular 
forms  of  after-cataract  has  now  become  an  extremely  safe 
measure,  and  affords  a  more  certain  promise  of  per- 
manently clear  vision,  the  gain  from  the  use  of  capsule 
forceps  does  not  appear  very  great.  It  is  more  particularly 
in  cases  where  the  capsule  is  opaque  and  inelastic  at  the 
time  of  operation  that  simple  division  is  likely  to  be  in- 
sufficient. But  here  the  use  of  capsule  forceps  alone 
becomes  dangerous,  since  the  toughened  capsule  may 
prove  more  resistant  than  the  surrounding  zonule. 

How  do  the  advantages  weigh  against  the  risks  ?  There 
is  a  real,  though  small,  danger  of  loss  of  vitreous  from 
depression  of  the  lens  in  seizing  the  capsule,  or  through 
movement  of  the  globe  with  the  forceps  in  the  eye,  or 
from  the  displacement  of  the  lens  by  the  drag  upon  a 
tough  capsule.  The  question,  like  so  many  others  in 
cataract  work,  is  not  one  of  absolute  right  or  wrong,  but  is 
rather  one  of  the  selection  of  suitable  cases.  Perhaps  the 
risk  attaching  to  the  use  of  the  forceps  may  be  quite 
eliminated  by  utilizing  them  only  upon  steady  eyes  and 
suitable  cataracts. 

*  Brit.  Med.  Joiiru.,  1905,  ii,  p.  433. 

16 


242  Cataract  Extraction 

My  personal  experience  of  the  method  is  a  small  one,  dating 
some  years  back.  With  either  Terson's  forceps  or  Rochon- 
Duvigneaud's  modification  I  tore  away  anterior  capsule  in  ten 
operations,  and  tried,  but  failed,  to  seize  the  capsule  on  eight 
other  occasions.  In  all  but  one  of  these  eight  eyes  the 
cataract  was  of  the  swollen,  liquefying  variety,  and  the  capsule, 
therefore,  presumably  tenser  than  normal.  In  one  case  I 
certainly  depressed  the  lens  a  little,  and  got  an  escape  of 
vitreous,  and  in  one  other  eye  the  lens  appeared  to  have  been 
a  little  displaced  by  the  forceps,  but  no  vitreous  was  lost.  I 
did  not  dare  to  use  the  instrument  except  in  very  quiet 
patients,  and  with  transparent  capsule.  It  appeared  to  me  to 
be  a  clumsy,  troublesome,  and  dangerous  instrument  compared 
with  the  cystitome,  and  I  did  not  feel  impelled  to  persevere 
with  it. 

De  Wecker  uses  forceps  only  in  docile  patients,  Sattler 
unless  the  capsule  is  tense,  Lagrange  unless  the  capsule  is  too 
dense.  Kuhnt  uses  forceps  or  cystitome  "  according  to  cir- 
cumstances." 

Birnbacher*  outlines  a  piece  of  capsule  with  a  special  knife 
to  avoid  leaving  loose  shreds  behind. 

Puncture  of  Posterior  Capsule. — Puncture  of  the 
posterior  capsule  after  extracting  the  lens  and  completing  the 
toilet  of  the  eye  appears  to  be  occasionally  indicated.  Where 
it  is  obvious  that  discission  is  needed  for  some  central  opacity 
of  the  posterior  capsule,  it  saves  trouble  to  perform  it  at  once, 
instead  of  as  a  supplementary  operation  a  fortnight  later.  But 
the  patient  must  be  steady  and  there  must  be  no  trace  of 
vitreous  tension,  for  one  has  no  right  to  risk  loss  of  vitreous. 
I  have  practised  it  rarely,  using  the  cystitome,  but  not  always 
without  vitreous  accident.  The  forward  pressure  of  the 
vitreous  distends  the  small  opening,  but  evidently  does  not 
always  continue  to  do  so,  for  Schweigger  sometimes  found  no 
trace  of  the  opening  later.  The  procedure  was  advocated 
especially  by  Hasner.f  It  was  practised  earlier,  not  only  to 
anticipate  trouble  from  after-cataract,  but  also  to  raise  the 
cornea  by  the  displacement  of  vitreous  for  the  adjustment  of 
the  wound  margins  in  cases   of  rigid   sclerotic   and   corneal 

*  Cbl.f.pr.  A.,  1894,  S.  70. 

t  Prager  Med.  Wochetischr.,  1864. 


Variations  in  Procedure,  and  their  Value     243 

collapse.     Sometimes  a  fairly  extensive  vertical  incision  was 
made  in  the  capsule. 

It  is  best  done  with  the  lids  separated  merely  by  finger 
traction.  Hasner  used  a  cataract  needle  for  tearing  the 
capsule.  Pressure  upon  the  globe  with  the  bandage  must  be 
carefully  avoided  afterwards. 


INTRAOCULAR  IRRIGATION. 

The  removal  of  lens  cortex  by  intraocular  irrigation 
appears  to  have  been  first  practised  by  Guerin  and 
Sommer*  toward  the  latter  end  of  the  eighteenth  century. 
Water  was  injected,  plain  or  with  additions.  Forlenze 
(1799)  used  a  graduated  syringe  with  flattened  nozzle. 
Maunoir  simply  allowed  fluid  to  enter  through  the  wound 
from  the  conjunctival  sac.  The  procedure  was  not  gener- 
ally adopted.  It  fell  into  disuse,  and  was  forgotten  until 
started  anew  by  McKeown  in  i884.t  His  report  was 
quickly  followed  by  others  from  Inouye  (Tokio),  Panas, 
Vacher,  and  Wickerkiewicz  in  1885  and  later.  The  method 
gained  many  adherents,  especially  in  France.  McKeown 
endeavoured  particularly  to  facilitate  operation  upon 
unripe  and  partial  cataracts ;  with  this  object  he  injected 
fluid  within  the  lens  capsule  by  a  sharp-pointed  needle 
before  attemptmg  expulsion.  One  of  the  oldest  uses  of 
the  introduction  of  fluid  into  the  eye,  still  taken  advantage 
of,t  was  to  restore  the  curvature  of  a  collapsed  cornea  or 
collapsed  eyeball,  whether  after  vitreous  loss  or  not. 
Vacher  and  Panas  hoped  by  the  use  of  antiseptic  solutions 
to  destroy  infective  organisms  in  the  wound  and  in  the 
chambers.     As  already  mentioned,  de  Wecker,  Hofmann, 

*  See  Magnus,  A.f.  O.,  xxxiv  (1888),  2,  167. 
t  Report  at  the  Brit.  Med.  Association  Meeting  at  Belfast. 
X  By    Knapp,    Lippincott   and    Pooley   in   America,  by   Elliot   in 
Madras,  and  doubtless  by  many  others. 

16 — 2 


244  Cataract  Extraction 

and  Elliot  have  insisted  upon  the  value  of  irrigation  for 
replacing  the  iris  in  position. 

A  number  of  solutions  have  been  employed,  including 
distilled  water,  normal  saline,  chlorine  water,  solutions  of 
boric  acid,  perchloride,  iodide  and  cyanide  of  mercury, 
alcohol,  trichloride  of  iodine,  etc.  Nuel  and  Cornil*  and 
Mellingert  came  to  the  conclusion  that  the  only  fluids 
applicable  among  a  considerable  number  tested  were 
sterilized  normal  saline  and  concentrated  boric  acid  solu- 
tion. Others  were  liable  to  cause  permanent  opacity  of 
the  cornea  by  destruction  of  its  endothelial  lining.  Irriga- 
tion is  at  present  practised  a  good  deal  in  India.  Many 
prominent  surgeons,  however — e.g.,  Fuchs  and  Pagen- 
stecher — regard  it  as  either  dangerous  or  superfluous.  In 
Bombay  we  had  ten  years'  experience  of  it,  extending 
probably  to  about  four  thousand  operations.  For  years 
the  douche  was  employed  as  freely  as  the  needs  of  the 
cases  suggested,  without  thought  of  possible  evil  conse- 
quences. During  this  period  we  were  able  practically  to 
exclude  panophthalmitis  as  a  complication.  But  milder 
infections  occurred,  shown  by  iritis  and  irido-cyclitis  of 
varying  degrees  of  intensity.  And  in  trying  to  get  rid  of 
these  complications  during  the  last  few  years  we  were 
forced,  by  a  process  of  exclusion,  to  the  opinion  that 
irrigation  was  responsible  for  at  least  some  of  them. 
Latterly  better  results  were  obtained  under  a  much  more 
restricted  use  of  the  method.  There  were  fewer  muddy 
pupils  found  the  day  after  operation,  and  attacks  of  iritis 
and  irido-cyclitis  became  rarer  and  milder  (see  '  Asepsis'). 

In  our  experience,  then,  the  infective  risks  of  intraocular 
irrigation  are  real  but  small,  the  accidents  not  being  of 
the  gravest.     By  proper  management  and  by  restriction  of 

*  Arch.  d'Opht.,  x  (1890),  319. 
t  A./.  O.,  xxxvii  (1891),  4,  159. 


Variations  in  Procedure,  and  their  Value     245 

the  application  of  the  method,  as  shown  in  Chapter  II,  it 
may  be  employed  without  incurring  any  appreciable  risk 
at  all.  In  this  connexion,  however,  our  treatment  of  the 
conjunctiva  with  strong  perchloride  must  be  borne  in 
mind.  Possibly  without  this  conjunctival  douching 
infective  accidents  attributable  to  the  intraocular  irriga- 
tion might  have  proved  more  serious. 

I  have  never  hesitated  to  wash  out  blood  early  in  the 
operation  to  facilitate  the  capsulotomy.  There  is  not  the 
same  probability  of  some  of  the  fluid  being  left  in  the  eye 
at  this  stage  of  the  operation,  as  later,  after  expulsion  of 
the  lens. 

The  fear  of  infecting  the  wound  from  the  conjunctiva, 
just  as  by  over-free  instrumentation,  has  deterred  many 
from  trying  the  method,  while  the  occurrence  of  un- 
explained accidents*  has  induced  others  to  give  up  the 
method  after  trial.  Captain  Gidney,  I.M.S.,t  relates  two 
instances  of  panophthalmitis  where  the  evidence  against 
irrigation  was  strong.  He,  irrigating  presumably  after 
removal  of  the  speculum,  or  with  the  speculum  not 
elevated  by  the  assistant,  suggests  that  the  patient's  head 
should  be  not  only  tilted  to  the  side  but  should  be  well 
elevated,  with  chin  depressed,  to  keep  the  wound  above  the 
level  of  the  conjunctival  fluid.  He  alludes  also  to  a 
minor  drawback  which  the  method  presents  to  surgeons 
who  have  to  operate  without  trained  assistance.  Unless 
they  take  the  trouble  personally  to  ensure  that  the  fluid 
and  apparatus  are  properly  sterilized,  there  must  be  reason 
to  fear  the  introduction  of  infective  material  into  an  eye 
directly  from  these  sources — sources  which  are  placed 
beyond  consideration  in  fully  staffed  and  equipped  hospitals. 

*  McKeown  had  one  suppuration  and  two  cases  of  uveitis  in  146 
extractions.  Lippincott  two  suppurations  and  one  occluded  pupil  in 
100  operations. 

t  Ind.  Med.  Gazette,  xlii  (1907),  450. 


246  Cataract  Extraction 

A  hard-worked  surgeon  can  scarcely  be  expected  to  find 
time  for  such  details  unless  very  decided  benefit  is  to  be 
derived  from  them. 

In  another  way  it  has  been  held  (Chibret,  Czermak), 
that  irrigation  may  work  indirectly  against  infection  of  the 
eye.  It  may  lessen  the  opportunities  for  the  multiplica- 
tion of  organisms  within  the  globe,  by  ensuring  the  more 
complete  removal  of  debris  upon  which  the  organisms 
might  thrive.  But  one  must  be  careful  not  to  lay  too 
much  stress  upon  this  point.  The  irrigation  may  be  directly 
responsible  for  an  early  non-infective  reactive  exudation 
of  lymph,  in  which  bacteria  might  establish  themselves. 
Maynard  says:*  "Twenty-four  hours  after  an  extraction 
with  irrigation  the  anterior  chamber  sometimes  looks  as  if 
filled  with  commencing  lymph.  This  all  clears  away  by 
the  second  or  third  day."  We  have  thought,  too,  that  some 
of  our  muddy  pupils  and  irises,  seen  on  the  day  following 
operation,  were  ascribable  to  over-free  douching.  Possibly 
this  reaction  is  preventable.  It  may  be  due  to  the  use  of 
fluid  at  an  unsuitable  temperature.  Using  the  one  flask 
for  a  number  of  operations,  our  solution  often  became 
cooled  too  much.  (In  a  colder  climate  much  more  care 
would  have  been  needed  to  keep  the  temperature  of  the 
fluid  nearly  correct).  Wanless  (Miraj,  India)  thought  that 
prolonged  syringeing  gave  rise  to  striped  keratitis  in  some 
of  his  cases. 

Other  accidents  due  to  irrigation  are  of  comparatively  little 
importance  because  of  their  rarity.  It  is  obviously  possible  to 
do  considerable  damage  with  the  cannula  in  the  eye.  Yet  I 
have  only  once  seen  loss  of  vitreous  apparently  attributable  to 
irrigation.  The  accident  immediately  followed  the  use  of  the 
douche,  but  I  believe  the  zonule  had  been  ruptured  previously. 
On   one   other   occasion  the   tip  of  the  cannula  was  thrust 

.    *  '  Manual  of  Ophthalmic  Operations,'  Calcutta  (1908),  p.  66. 


Variations  in  Procedure,  and  their  Value     247 

through  the  posterior  capsule  by  sudden  movement  of  the 
globe,  but  no  vitreous  prolapsed.  Dr.  J.  H.  Claiborne 
(America)  reported  that  he  once  saw  extensive  irido-dialysis 
caused.  "  Irrigation  had  been  performed  with  but  slight 
pressure  with  a  curette."  In  Bombay  we  once  had  a  very 
unfortunate  experience.  Fluid  containing  a  little  sublimate 
was  used  on  two  successive  days.  Twenty-two  cataracts  were 
extracted,  and  irrigation  was  practised  in  varying  quantity  in 
nearly  all  of  the  cases.  Seventeen  of  the  corneas  were  made 
permanently  opaque  in  varying  degree.  The  vision  was 
reduced  to  perception  of  moving  bodies  in  a  few  cases,  and  at 
least  three  of  the  eyes  developed  secondary  glaucoma.  The 
accident  was  due  to  the  tubes  having  been  put  into  the  flasks 
filled  with  the  sublimate  solution  in  which  they  were  sterilized. 

There  is  no  question  that  irrigation  was  on  the  whole  of 
great  use  to  us,  removing  cortex  more  completely,  easily, 
and  quickly  than  would  have  been  possible  otherwise,  and 
enabling  us  to  extract  unripe  cataracts  upon  which  we 
would  otherwise  not  have  ventured  to  operate.  It  enabled 
us  also  to  utilize  a  complete  conjunctival  flap  without 
serious  inconvenience,  in  the  days  before  we  instilled 
adrenalin  solution.  The  wound  margins  were  left  cleaner, 
and  this  must  have  helped  to  promote  rapid  union. 

The  use  of  the  douche  is  contra-indicated  in  cases  of 
threatened  or  actual  escape  or  prolapse  of  vitreous,  and 
therefore  in  intracapsular  extraction  of  the  lens.  Though 
it  is  employed  to  fill  the  anterior  chamber  in  collapse  of 
the  cornea  and  in  collapse  of  the  globe,  whether  after 
vitreous  loss  or  not,  it  is  probably  unnecessary  for  this 
purpose,  at  least  in  operations  with  a  conjunctival  flap. 

THE  OPEN  TREATMENT  OF  THE  WOUND. 

Numerous  objections  have  been  urged  against  the  occlusive 
dressing  :  (i)  It  has  a  tendency  to  induce,  or  to  exaggerate 
already  existing,  conjunctival  injection  and  secretion.  The 
heat  of  the  dressing  and  the  stagnation  of  the  fluid  in  the  con- 


248  Cataract  Extraction 

junctival  sac,  due  to  the  stoppage  of  the  blinking  movements 
of  the  hds,  promote  the  development  and  retention  of  micro- 
organisms. The  '  physiological  toilet '  of  the  eye  is  interfered 
with.  (2)  The  bandage  is  liable  to  displacement  by  restless- 
ness during  sleep,  and  it  may  then  do  harm  by  pressing 
unevenly  upon  the  globe.  (3)  The  pressure  of  a  bandage  too 
tightly  applied  may  cause  prolapse  of  iris  (see  also  p.  147). 

(4)  Frequent  inspection  of  the  lids  is  rendered  impracticable. 

(5)  The  double  covering  has  been  responsible  at  times  for  the 
development  of  mental  depression  or  delirium. 

But  these  disadvantages  may  be  largely  eliminated  by  care 
in  covering  the  eye,  and  by  limiting  the  period  of  application 
of  the  dressing.  And  there  is  the  benefit  of  immobility  of  the 
eye  while  the  double  bandage  is  in  place.  Praun*  and 
Czermakt  have  especially  recommended  what  is  sometimes 
known  as  the  '  modified  open  '  or  the  '  German  '  method  by 
*  hollow  dressing.'  The  eyes  are  covered  only  by  a  double 
Fuchs'  shield,  well  padded  at  the  margins  to  fit  closely,  and 
covered  by  black  cloth  to  exclude  light  and  dust.  Thus  com- 
pletely shaded,  the  lids  are  commonly  kept  closed  and  the  eyes 
immovable,  almost  as  continuously  as  if  fixed  by  a  dressing. 
Czermak  got  less  reopening  of  the  wound  than  with  an 
occlusive  dressing.  Fuchs  applies  a  dressing  under  the  mask, 
held  by  a  single  strip  of  linen  fixed  with  soap  plaster.  Wicker- 
kiewicz,:!:  following  Wolff  berg,  simply  covers  the  eye  with 
strong  brown  silk  paper,  cut  to  the  required  shape,  and  pasted 
to  the  skin  over  the  orbital  margin  with  ordinary  gum  arable. 

For  similar  occlusion  without  dressing,  Doyne  §  employs  a 
cast  of  dentist's  wax,  moulded  beforehand.  The  mask  extends 
beyond  the  orbital  margins.  After  the  cast  has  set  it  is  removed, 
and  its  central  portion — that  which  covers  the  eye — cut  away. 
It  is  then  replaced,  and  the  defect  made  good  with  soft,  heated 
wax,  which  does  not  adhere  to  that  which  has  already  set. 
This  loose  central  portion  overlaps  the  other.  After  it  has  set 
it  is  thinned,  by  scraping,  to  remove  it  from  contact  with  the 
eyelids,  and  perforated  for  ventilation.  The  wax  must  be 
hard  or  it  may  not  withstand  the  heat  of  the  face  sufficiently. 

In  our  Bombay  work  a  large  absorbent  dressing  was  neces- 

*  Cbl.f.pr.  A.,  Marz,  1898.  f  Ibid.,  Mai,  1898. 

X  Kl.  Mounts,  f.  A.,  xlii  (1904),  2,  222. 
§  Method  shown  at  Oxford,  July,  1907. 


Variations  in  Procedure,  and  their  Value     249 

sary  at  least  for  a  day,  to  receive  the  fluid  poured  out  from  the 
conjunctiva,  irritated  by  the  strong  perchloride  lotion.  Where 
there  is  this  watery  discharge  the  dressing  is  needed,  both  for 
the  sake  of  cleanliness  and  to  obviate  wiping  and  rubbing  by 
the  patient,  and  to  prevent  excoriation  of  the  skin.  Otherwise, 
there  seems  to  be  little  advantage  in  retaining  the  occlusive 
dressing  longer  than  twenty-four  hours.  Observation  tends  to 
narrow  the  period  of  origin  of  most  of  the  serious  complications 
to  the  few  hours  immediately  following  operation.  And  the 
advantages  of  immobilization  after  this  period  are  appreciable 
only  in  the  case  of  unreasonable  and  unintelligent  patients.  In 
many  of  these,  however,  the  unoperated  eye  must  be  left 
uncovered  from  the  beginning. 

Some  surgeons  have  used  the  wire  shield  alone  from  the 
beginning,  others  transparent  celluloid  shells  fixed  by  adhesive 
strapping  along  their  margins  and  by  tapes.  These  are 
decidedly  preferable  to  the  completely  open  treatment  of 
Hjort,*  affording  no  protection  of  any  kind  against  light  or 
injury. 

Czermak  found  closure  of  the  lids  by  a  strip  of  court  plaster 
necessary  (i)  when  the  lid  space  was  so  wide  as  to  expose 
the  (upper)  section ;  (2)  when  the  section  had  been  made 
below,  and  was,  therefore,  necessarily  exposed  between  the 
lids  ;  and  (3)  after  loss  of  vitreous.  A  pressure  bandage  was 
considered  advisable  where  intraocular  haemorrhage  was  feared, 
as  in  glaucoma. 

For  various  reasons  cataract  patients  have  been  treated 
from  the  beginning  as  out-patients,  walking  to  their  homes  a 
few  hours  after  operation.  In  up-country  practice  in  India 
this  may  be  at  times  necessary.  Darier  finds  that  such  cases 
do  practically  as  well  as  indoor  patients. 

REMOVAL   OF   THE    LENS   TOGETHER   WITH 
ITS   CAPSULE. 

From  the  earliest  days  of  cataract  extraction  operators 
have  made  occasional  involuntary  acquaintance  with  the 
delivery  of  the  lens  in  its  unbroken  capsule.     It  happened 

*  First  published  in  the  Cbl.  f.  pr.  A.,  Mai,  1897.  See  also 
Mohilla's  results,  Cbl.  f.  pr.  A.,  December,  1899. 


250  Cataract  Extraction 

in  two  ways.  Either  it  was  a  pure  accident  in  which  the 
surgeon  had  no  direct  participation,  the  lens  being  shot 
out  by  reflex  closure  of  the  lids,  generally  with  more  or 
less  vitreous.  Or,  owing  to  rupture  of  the  zonule,  whether 
at  the  time  of  operation  or  earlier  (in  cases  of  dislocated 
lens),  escaping  vitreous  necessitated  the  introduction  of  a 
spoon  or  loop  behind  the  lens  to  extract  it.  And  the  same 
instrumental  extraction  was  sometimes  practised  owing  to 
a  difficulty  experienced  in  opening  the  thickened  opaque 
capsules  of  some  overripe  cataracts,  or  owing  to  the  fear 
of  pressing  upon  tremulous  lenses  with  the  cystitome. 

A.  Pagenstecher  first  introduced  the  deliberate  routine 
extraction  of  all  senile  cataracts  in  their  capsules.  The 
method  was  published*  in  September,  1865,  at  the 
Heidelberg  Ophthalmological  Congress.  The  brothers 
Pagenstecher  later  restricted  the  application  of  the 
methodt  to  the  compulsory  cases  (dislocated  lenses),  and 
to  those  in  which  the  risks  of  rupture  of  the  capsule  and  of 
loss  of  vitreous  by  this  method  were  found  to  be  least. 
This  group  included  all  overripe  cataracts,  including 
Morgagnian  and  shrunken  and  calcified  lenses,  in  which 
the  generally  thickened  capsule  might  be  expected  to 
prove  stouter  than  the  possibly  atrophic  zonule.  Also 
cataracts  in  eyes  with  pupil  occluded  by  irido-choroiditis, 
because  in  these  cases  the  lens  was  loosened  in  the  fossa 
patellaris.  The  operation  was  found  to  be  inapplicable  in 
unruly  patients,  and  in  eyes  with  vitreous  tension,  and  for 
cataracts  which  were  barely  ripe  and  had  ripened  rapidly, 
whether  the  ripening  were  natural  or  artificial.  The  tense 
capsules  of  these  swollen  lenses  was  liable  to  burst 
during  the  extraction.     The  procedure  also  was  modified 

*  Personal  communication  from  H.  Pagenstecher. 
t   H.    Pagenstecher,   '  Die   Extraction   des    grauen   Stars    in    der 
geschlossen  Kapsel'  (Wiesbaden,  1873). 


Variations  in  Procedure,  and  their  Value     251 

by  Hermann  Pagenstecher.  In  the  earlier  operations  a 
large  shallow  spoon  (Fig.  38)  was  inserted  for  the  with- 
drawal of  the  lens,  after  an  iridectomy  had  been  made. 
Later  it  was  found  safer  to  pass  in  the  spoon  only  a  little 
way  between  the  lens  and  the  vitreous,  to  serve  as  an  in- 
clined plane  to  guide  and  support  the  lens,  and  to  keep 
the  vitreous  back.  Pressure  was  placed  upon  the  globe 
by  the  assistant  with  a  spatula  (Fig.  32)  at  the  lower 
corneal  margin.  Only  when  moderate  pressure  thus 
applied  failed  to  expel  the  lens,  was  the  edge  of  the  spoon 
passed  down  beyond  the  posterior  pole  of  the  lens,  to 
obtain  an  upward  pull  upon  the  lens,  and  so  to  assist  in  its 
delivery.  At  times  the  spoon  was  not  introduced  into  the 
globe  at  all,  but  merely  used  for  depressing  the  upper  lip 
of  the  wound. 

At  the  present  day  H.  Pagenstecher  does  not  perform 
intracapsular  extraction  so  frequently  as  in  former  days, 
because  he  operates  generally  without  iridectomy,  and 
because  "the  healing  process  is  generally  prolonged  if 
there  is  an  escape  of  even  a  little  vitreous,"  and  because 
overripe  cataracts  are  getting  rare  nowadays  in  Europe. 

Numerous  modifications  in  technique  have  been  introduced 
from  time  to  time  without  gaining  any  general  adoption. 
Some  of  the  modifications  have  been  intended  for  application 
to  senile  cataracts  in  general,  others  for  restricted  use  only. 
The  wire  loop,  forceps,  and  hook  have  all  been  employed  for 
extracting  the  lens.  Macnamara*  made  an  outer  section 
without  iridectomy,  but  with  previous  dilatation  of  the  pupil. 
He  introduced  a  spoon  and  depressed  the  near  edge  of  the  lens, 
causing  the  latter  to  rotate,  so  that  it  was  withdrawn  with  its 
posterior  surface  foremost.  Dr.  Andrew!  operated  in  the 
same  manner,  except  that  he  tore  the  zonule  at  the  inner  side 
of  the  lens  with  a  wire  hook,  introduced  either  through  the 
incision   or,   before   making   the   incision,   through   an    outer 

*  'A  Manual  of  the  Diseases  of  the  Eye,'  2nd  edition,  1871. 
t  Brit.  Med.  Journ.,  January,  1883,  p.  41. 


252  Cataract  Extraction 

puncture.  Various  other  attempts  have  been  made  to  aid  in 
the  expulsion  of  the  lens  by  division  of  the  zonule.  Cannstatt 
(1870)  dislocated  the  lens  into  the  anterior  chamber  after 
making  the  incision,  by  means  of  a  needle  previously  inserted 
through  the  sclerotic.  Roosa  (1885)  tore  the  zonule  by  partly 
dislocating  the  lens  with  the  knife.  Gradenigo*  (1895)  ^^'^ 
his  school  have  more  recently  practised  separation  of  the  lens 
from  its  attachments  by  a  '  zonulotome,'  or  blunt  hook  with 
stem  curved  to  correspond  with  the  lens  surface,  and  also  bent 
like  the  ordinary  Graefe's  cystitome.  One  of  his  pupils,  Ovio, 
from  experimental  investigation  upon  animals'  eyes,  finds  that 
the  risk  of  vitreous  loss  is  least  with  only  a  limited  division  of 
the  zonule.  All  of  these  attempts  have  been  overshadowed  by 
the  recent  development  of  the  intracapsular  operation  in  India; 
but  Wolkow's  f  delivery  of  the  lens  by  pressure  and  counter- 
pressure  with  two  spoons  requires  mention. 

The  work  in  India  was  begun  t  by  Mulroney,  at  Amritsar 
in  the  Punjab,  in  i8go.  He  made  a  downward  section 
without  iridectomy,  and  expelled  the  lens  by  manipula- 
tion. Henry  Smith  at  Jullundur,  also  in  the  Punjab, 
adopted  the  method,  but  preferably  with  an  upper  section, 
and  latterly  with  iridectomy.  Obtaining  better  results,  he 
has  expanded  the  work  greatly.  In  1893,  1,145  of  these 
operations  were  performed  at  Amritsar.  Now  the  extrac- 
tions at  Jullundur  number  nearly  three  thousand  per 
annum. §  In  the  year  from  May  31,  1904,  to  May  31, 
1905,  Smith  extracted  2,616  cataracts  in  their  capsules, 
and  only  151  with  capsulotomy.  ||  With  this  extra- 
ordinary experience  he  has  clearly  and  authoritatively 
established  expression  as  the  correct  method  of  delivering 
the  lens  in  its  capsule,  and  has  shown  that  it  is  applicable 

*  Saggini,  Ann.  d'OcuL,  cxxii  (1899),  344. 
i-    Wjestttik  Ofial.,  xi  (1894),  366. 

X  Meher  Chund,  Rai  Bahadur.     '  New  Operation  for  Cataract  at 
Civil  Hospital,  Amritsar.'     Trans.  Ind.  Med.  Congress.,  1894. 
§  Ind.  Med.  Gazette.,  xlii  (1907),  326. 
ii  Ibid..,  xl  (1905),  327  ;  and  Archives  of  Ophth..^  xxxiv  (1905),  601. 


Variations  in  Procedure,  and  their  Value    253 

to  the  large  majority  of  senile  cataracts.  He  has  obtained 
such  unexpectedly  good  results  that  he  has  now  many 
imitators  in  India ;  and  ophthalmic  surgeons  generally, 
especially  in  America,  are  more  ready  to  use  the  method 
than  formerly.  Intracapsular  expression  is  not  infre- 
quently spoken  of  as  '  Smith's  operation.'  Smith  practises 
ordinary  extraction  only  in  children  and  for  "  atrophic  " 
cataracts,  and  for  others  with  "  semi-gelatinous  "  cortex  of 
a  bluish  tinge — evidently  the  rapidly  ripening  cataracts  of 
Pagenstecher. 

Operative  Procedure. 

Smith  says  "the  details  of  the  operation  which  I 
perform  are  my  own,"  and  insists  that  men  must  see  it 
done  in  order  to  learn  the  method  completely.  On  the 
contrary,  I  can  find  no  detail  which  has  not  been  practised 
earlier  by  others.  The  originality  in  Smith's  method,  if 
there  be  any,  lies  apparently  in  the  omission  of  detail.  And 
those  who  have  seen  Smith  operate  do  not  appear  to  have 
benefited  much,  judging  from  their  results.  The  operation 
is  merely  ordinar}'  combined  extraction,  with  the  omission 
of  one  step — the  opening  of  the  capsule. 

Unless  the  patient  be  very  quiet  and  reliable,  the  stop- 
speculum  is  replaced  by  retractor  for  the  upper  lid,  and 
finger  depression  of  the  lower  lid,  before  the  expulsion  of 
the  lens  is  attempted.  Smith  prefers  a  large  strabismus 
hook  to  Desmarres'  retractor.  But  with  his  left  hand  he 
also  inserts  a  spoon  or  vectis  under  the  upper  lid  "  to 
raise  that  half  of  it  which  is  not  so  fully  raised  by  the 
assistant's  blunt  hook.  This  may  be  placed  at  the  nasal 
or  temporal  side,  according  to  the  operator's  predilection."* 
The  control  of  the  peripheral  fibres  of  the  orbicularis  has 
been  already  mentioned  p.  go. 

*  Rutter  Williamson,  The  Ophthabnoscope^  v  (1907),  556. 


2  54  Cataract  Extraction 

With  the  assistant  standing  at  the  patient's  right  side, 
the  operator  has  to  pass  his  right  hand  under  the  assis- 
tant's left  wrist  in  operating  on  the  left  eye.* 

Few  surgeons  will  be  inclined  to  follow  Smith  in  making  a 
purely  corneal  section,  with  puncture  and  counter-puncture 
at  the  limbus,  either  in,  or  i  millimetre  above,  the  hori- 
zontal corneal  meridian,  and  the  summit  of  the  arch  "  half- 
way between  a  normal  pupil  and  the  sclero-corneal 
junction."  Through  this  low  section  Smith  is  able  to 
deliver  the  lens  whatever  be  the  position  of  the  eye. 
He  "  lays  stress  upon  not  making  the  patient  look  down, 
as  doing  so  encourages  prolapse. "-}- 

He  employs  a  strabismus  hook  for  expressing  the  lens, 
as  was  done  also  earlier  at  Amritsar.  He  does  not  now 
make  use  of  counter-pressure  above  the  wound  with  a 
spoon,  as  he  did  formerly.  "  He  finds  there  is  less  risk  of 
vitreous  escaping  if  no  counter-pressure  be  used,  and  the 
expression  of  the  lens  is  almost  as  easy,  although  a  trifle 
slower. 

"With  his  right  hand  he  places  the  convexity  of  a 
strabismus  hook  upon  the  cornea,  over  the  junction  of  the 
lower  with  the  middle  third  of  the  lens.  This  is  not 
altered  in  position  till  the  lens  is  half-way  out.  The  pressure 
is  directed  to  the  back  of  the  eye,  and  at  first  is  neither 
towards  the  wound  nor  from  it,  though  when  the  lens  has 
started  on  its  way  there  is  an  almost  unconscious  slight 
adaptation  of  pressure  toward  the  free  edges  of  the  wound. 
When  the  lens  is  half-way  out  the  hook  is  sKifted,  so  as  to 
tilt  to  some  extent  the  edge  of  the  lens  into  the  concavity 
of  the  hook.  If  the  lens  sticks,  the  hook  is  moved  to  one 
or  other  side  without  lifting  it  from  cornea  or  relaxing  its 
pressure,  so  as  to  try  and  disengage  the  peripheral  portions. 

*  Maynard,  '  Manual  of  Ophthalmic  Operations'  (1908),  p.  no. 
t  Ibid.,  p.  112. 


Variations  in  Procedure,  and  their  Value    255 

"  The  pressure  exerted  is  moderate,  slow  and  continuous, 
gradually  relaxing  in  amount  as  the  lens  is  seen  to  be  well 
on  its  outward  way.  The  process  must  be  done  slower, 
and  with  much  more  deliberation  than  in  the  capsule- 
laceration  operation.  The  continued  pressure  quickly 
tires  out  the  iris,  which  dilates  and  allows  the  lens  to 
emerge  very  like  the  process  of  parturition.  If  the  ex- 
pression be  attempted  rapidly,  the  capsule  will  probably 
burst  just  as  it  is  coming  out.  If  this  accident  does 
happen,  it  is  best  to  keep  up  the  pressure  with  the  hook, 
so  that  the  capsule  does  not  retract,  and  try  and  gently 
drag  it  out  with  a  pair  of  ordinary  dissecting  forceps 
applied  to  the  part  outside  the  wound.  The  broad  hold 
so  secured  will  often  succeed  in  drawing  out  the  whole  of 
it  with  its  contained  lens  matter. 

"  During  all  this  manipulation  the  patient  is  not  spoken 
to,  nor  asked  to  aid  in  any  way,  either  by  looking  up  or 
down.  To  do  so,  most  of  us  have  probably  found,  more 
often  flusters  the  already  nervous  patient  than  succeeds  in 
getting  him  to  do  promptly  what  is  requested  of  him.  As 
a  consequence,  the  generality  of  patients  will  be  found  to 
turn  the  eye  so  that  it  looks  high  up  into  the  superior 
fornix.  ... 

"  This  is  an  awkward  position  for  the  surgeon,  though 
the  extraction  can  quite  well  be  performed  with  the  eye  in 
this  position,  provided  the  assistant  holds  the  lids  as 
described."* 

Maynard  says :  "  When  the  lens  is  half  out  it  will  some- 
times be  found  that  .  .  .  the  operation  seems  to  come  to  a 
standstill.  In  such  cases,  while  keeping  up  pressure  with 
the  strabismus  hook,  the  lens  may  be  gently  coaxed  out  by 
means  of  a  spoon  applied  along  its  edge  with  safety, 
provided  the  spoon  be  rounded  and  not  sharp,  and  great 

*  Rutter  Williamson,  loc.  cit. 


256  Cataract  Extraction 

gentleness  be  used,  so  as  not  to  rupture  the  capsule."* 
Another  aid  is  "  to  slowly  slide  the  counter-pressing  spoon 
along  the  sclera  along  the  outer  edge  of  the  wound" 
(Maynard).  "  When  the  lens  is  half-way  out  ...  a  clear 
point  of  vitreous  will  occasionally  appear  in  the  wound 
behind  the  lens.  .  .  .  The  spoon  in  the  left  hand  .  .  . 
should  be  pushed  beneath  the  lens  through  the  clear  point 
and  the  lens  suspended  on  it.  Once  the  lens  is  supported 
on  the  spoon  the  strabismus  hook  can  be  used  as  before  to 
drive  out  the  lens,  the  spoon  merely  coming  with  the  lens, 
but  not  drawing  it  out.  ...  If  we  attempt  to  lift  out  the 
lens  on  the  spoon  merely,  the  capsule  will  give  way  with 
exceeding  frequency"  (Smith).t 

In  addition  to  this  occasional  insertion  of  the  spoon,  the 
iris  forceps  have  sometimes  to  be  introduced  to  seize 
ruptured  capsule.  "  If  the  capsule  has  retracted,  we  should 
try  by  gentle  stroking  to  press  out  its  contained  lens 
matter,  .  .  .  and  if  the  capsule  be  evident  to  the  eye,  we 
may  make  an  attempt  to  catch  it  with  an  iris  forceps  and 
fetch  it  out."t  Where  no  accident  occurs  the  only  instru- 
ment introduced  into  the  globe  is  the  knife.  Ordinary 
dissecting  forceps  are  used  for  seizing  ruptured  capsule 
lying  in  the  wound. 

The  amount  of  pressure  required  is  sometimes  con- 
siderable. Maynard  mentions  that  during  the  period  in 
which  he  performed  175  intracapsular  operations,  he  tried, 
but  failed  to  expel  the  lens  from  eight  other  eyes  with  the 
degree  of  force  which  he  felt  justified  in  applying.  After 
operation  the  same  care  is  demanded,  whether  there  has 
been  loss  of  vitreous  or  not.     At  Jullundur  both  eyes  are 

*  Ind.  Med.  Gazette,  xli  (1906),  315. 

t  Ibid.,  xl  (1905),  327.  According  to  Williamson  {loc.  cit.\  Smith 
introduces  the  same  spoon  into  the  eye  which  he  has  been  using 
for  supporting  the  upper  lid,  and  this  without  cleaning  it  in  any  way. 

X  Smith,  loc.  cit. 


Variations  in  Procedure,  and  their  Value     257 

bandaged,  and  the  coverings  are  not  disturbed  for  four 
days  unless  there  is  pain. 

Major  Newman  *  states  that  he  always  attempts  expulsion 
within  the  capsule,  but  if  the  lens  does  not  come  easily  he 
desists.  He  thinks  that  this  attempt  facilitates  the  delivery  of 
the  lens  in  the  ordinary  way  after  capsulotomy,  the  pressure 
applied  having  altered  the  shape  of  the  lens  and  detached  the 
cortex  from  the  capsule.  Captain  Gidneyf  performs  the 
intracapsular  operation  only  where  he  considers  the  making  of 
a  conjunctival  flap  unnecessary.  This  because  of  the  possi- 
bility of  trouble  from  blood  in  the  anterior  chamber,  which 
could  not  be  washed  out  J  after  the  zonule  had  been  ruptured. 
Trouble  from  haemorrhage  could,  however,  be  prevented  by 
the  instillation  of  adrenalin  beforehand. 

The  Drawbacks  of  the  Operation. 

I.  Loss  of  Vitreous. — The  question  of  the  applicability  of 
the  method  to  the  general  run  of  senile  cataracts  hangs 
mainly  upon  the  risk  of  vitreous  accidents,  with  their 
ultimate  consequences — infective  inflammations,  detach- 
ment of  the  retina,  atrophy  of  the  globe,  etc.  The  removal 
of  the  support  afforded  to  the  vitreous  by  posterior  capsule 
and  zonule  combined,  of  necessity  adds  to  the  number  of 
vitreous  escapes.  Even  without  external  pressure  the 
vitreous  tension  may  be  sufficient  to  cause  an  escape  as 
soon  as  an  opening  is  made  in  the  supporting  diaphragm. 
Smith's  extraordinarily  low  percentage  of  escapes — 
between  6  and  7  per  cent.,  published  in  I903,§  and  again 
in  190511 — came  as  a  revelation  of  the  possibilities  in  this 
respect.  And  it  is  said  that  this  rate  has  been  further  re- 
duced since  then.  Smith  claims  that  in  only  nine  instances 
among  2,616  extractions  did  the  loss  amount  to  more  than 

*  Ind.  Med.  Gazette^  xli  (1906),  403.  f  Ibid.,  xlii  (1907),  448. 

\  Maynard,  however,  considers  that,  if  the  vitreous  has  not  pro- 
lapsed, irrigation  may  be  employed  ('  Manual  of  Ophth.  Op.,'  p.  114). 
§  Brit.  Med.  Journ.,  September  26,  1903.  ||  Z/)c.  cit. 

17 


258  Cataract  Extraction 

"  a  bead  of  vitreous."  And  these  nine  accidents  were  "  in 
supremely  nervous  patients,  who  shot  out  the  lens  and  a 
quantity  of  vitreous  the  moment  the  incision  was  com- 
pleted. ....  The  accident  in  these  cases  would  have 
occurred  in  any  operation."  And  these  statistics  included 
the  extraction  of  seventy-five  lenses  couched  by  quacks. 
No  other  operator  has  succeeded  in  approaching  this 
low  percentage.  Captain  Oxley,*  a  beginner,  in  his  first 
series  of  forty  intracapsular  extractions  lost  vitreous  in 
30  per  cent,  of  the  cases.  In  a  second  series  of  forty  cases 
the  losses  amounted  to  40  per  cent.  Major  Birdwood,t  in 
a  total  experience  of  311  of  these  operations,  had  at  first 
vitreous  escape  in  47  per  cent,  of  the  cases,  later  in  37  per 
cent.  He  does  not  think  the  average  operator  can  expect 
to  reduce  the  proportion  of  accidents  below  30  per  cent. 
Maynard  +  lost  vitreous  in  38*28  per  cent,  of  the  cases  in  a 
series  of  175  intracapsular  operations.  By  the  ordinary 
method  he  had  4*3  per  cent,  of  vitreous  accidents  in  a  late 
series  of  a  thousand  extractions ;  in  an  earlier  series  of  a 
thousand  cases  the  percentage  was  6*3.  (For  other  figures 
showing  the  proportion  of  accidents  by  ordinary  extrac- 
tion, see  pp.  i6g  and  170.)  Drake  Brockman,§  operating 
by  Pagenstecher's  method,  had  28*67  per  cent,  of  vitreous 
losses  in  293  operations. 

2.  Rupture  of  the  Capsule  "when  the  lens  is  partly 
out,"  and  when,  therefore,  the  zonule  has  already  given 
way,  is  regarded  by  Smith  as  the  most  serious  accident 
met  with  at  the  time  of  operation.  Efforts  to  extract  the 
capsule  and  its  contained  cortex,  as  above  given,  may 
prove  unavailing.  Smith  had  to  leave  the  capsule  behind 
in  slightly  more  than  half  the  cases  of  rupture,  and  much 

*  Ind.  Med.  Gazette^  xl  (1905),  456,  and  xli  (1906),  482. 
t  Ibid.,  xli  (1906),  201.  X  Loc.  cit. 

§   The  Ophthalmoscope,  iv  (1906),  121. 


Variations  in  Procedure,  and  their  Value     259 

cortical  matter  was  often  left,  either  within  the  capsule  or 
lying  in  the  anterior  chamber.  He  does  not  mention  any 
attempts  to  remove  or  to  displace  the  capsule  later. 
Folded  capsule  and  cortical  remains  lying  in  the  pupillary 
area  must  often  interfere  greatly  with  vision.  Smith  had 
rupture  of  the  capsule  in  8  per  cent,  of  his  operations, 
Maynard  in  I7'i4  per  cent.  In  one-third  of  these  latter 
there  was  escape  of  vitreous  also.  Maynard  says :  "  More 
than  half  the  indifferent  and  nearly  half  the  bad  results  of 
the  whole  series  were  in  cases  in  which  the  capsule  had 
ruptured."  He  thinks  that  the  capsule  "loosened  from  its 
surroundings  is  more  likely  to  become  entangled  in  the 
wound."* 

3.  Incarceration  and  Prolapse  of  Iris  must  be  met  with 
somewhat  more  frequently  after  this  operation  than  when 
the  capsule  is  left.  This  follows  from  the  higher  pro- 
portion of  vitreous  accidents.  Birdwood  t  says  :  "  There 
seems  to  be  a  great  tendency  for  the  iris  to  be  caught  in 
the  angles  of  the  wound  at  each  side.  ...  If  the  vitreous 
is  escaping,  it  is  best  to  leave  them  alone."  Maynard  got 
prolapse  of  iris  five  times  and  incarceration  three  times  in 
his  175  operations.  He  says  this  is  above  the  average  of 
ordinary  combined  extraction.  Arnold  Knapp,|  during  a 
visit  to  Jullundur,  saw  17  prolapses  or  incarcerations  in 
104  intracapsular  extractions,  but  the  operations  were 
mostly  without  iridectomy.  The  complication  is  much 
more  serious  after  intracapsular  extraction,  because  the 
risk  of  loss  of  vitreous  in  removing  the  prolapse  is  much 
greater.  If  vitreous  has  already  been  lost  at  the  time  of 
operation,  any  attempt  at  early  excision  of  the  prolapse  is 
absolutely  barred. 

*  Against  this  is  to  be  counted  the  fact  that  in  the  numerous  cases 
in  which  the  operation  is  successful  there  is  no  capsule  left  to  become 
impacted. 

t  Loc.  cit.  \  Arch,  of  Ophth.,  xxxvii  (1908),  13. 

I  17 — « 


2  6o  Cataract  Extraction 

4.  Enlarged  Pupil. — Maynard  finds  that  even  where  there 
has  been  no  vitreous  escape  the  pupil  tends  to  be  noticeably 
enlarged.  The  distorted  and  displaced  pupils  after  some 
vitreous  losses  are  mentioned  on  p.  173.  Maynard  saw  drawing 
up  of  the  pupil  in  four  cases  in  which  there  had  been  no  loss 
of  vitreous,  and  in  which  there  was  no  iritis. 

5.  Corneal  Opacity. — Maynard  had  three  cases  of  permanent 
haziness  of  the  cornea,  with  low  tension  and  vision  only  the  per- 
ception of  moving  bodies  or  of  light.  In  one  of  these  cases  the 
wound  gaped  for  a  month,  and  lymph  appeared  in  the  wound. 

6.  Indefinite  Ailments. — Maynard  mentions  two  cases  in  which 
the  eye  remained  for  long  red,  painful,  and  slightly  chemosed, 
with  vision  never  good.  In  one  of  these  (possibly  infective) 
cases  the  pupil  became  drawn  up.  (This  is  in  addition  to  the 
four  cases  mentioned  above.)  Maynard  suggests  that  this 
irritability  of  the  eye  may  be  due  to  the  amount  of  pressure 
employed. 

7.  Delayed  Union  of  the  wound  was  complained  of  by  Maynard 
in  seven  of  his  cases,  in  spite  of  conjunctival  flaps  having  been 
made  in  six  of  the  cases. 

8.  Post-operative  Astigmatism  is  said  to  be  greater  after  intra- 
capsular extraction.* 

Advantages. — Some  surgeons,  impressed  by  Smith's 
reports,  are  inclined  to  *  strain  a  point '  in  favour  of  intra- 
capsular extraction,  feeling  that  it  gives  an  ideal  result 
when  successful.  But  there  is  no  doubt  that  a  successful 
ordinary  simple  extraction,  followed  by  satisfactory  early 
needling,  gives  a  slightly  superior  result.  Thus  a  small 
mobile,  perfectly  black  pupil  is  obtained,  to  compare  with 
the  widened  pupil  and  the  colobomaf  of  the  intracapsular 
method. 

I.  The  one  definite  advantage  of  the  method,  as  applied 
to  cataracts  which  can  be  extracted  in  the  usual  way,  is 

*  Czermak,  '  Die  Augen.  Operationen,'  S.  1047. 

f  Smith  formerly  performed  the  intracapsular  operation  frequently 
without  iridectomy,  but  his  later  practice  and  the  experience  of  others 
show  that  it  is  generally  unwise  to  omit  both  capsulotomy  and 
iridectomy. 


Variations  in  Procedure,  and  their  Value     261 

that  when  successful  it  once  and  for  all  time  eliminates  all 
possibility  of  trouble  from  after-cataract.  Until  recently 
this  was  a  considerable  gain,  and  even  now  it  is  often  an 
advantage  not  to  be  despised.  The  precise  value  of  the 
removal  of  the  capsule  is  this  : 

(a)  A  fair  proportion  of  the  patients  are  saved  from  the 
trivial  annoyance  of  an  insignificant  secondary  operation 
ten  or  twelve  days  after  the  extraction.  (In  Smith's 
work  it  is  an  advantage  that  the  patients  need  not  be 
kept  in  hospital  so  long  as  ten  or  twelve  days.) 

(6)  A  number  of  others  eventually  see  better  than  they 
would  do  under  the  usual  treatment.  This  applies  to 
cases  in  which,  after  ordinary  extraction,  there  does  not 
seem  to  be  sufficient  need  for  early  discission,  and  in 
which  after-cataract  develops  later.  Many  of  these 
patients  do  not  give  us  the  opportunity  of  remedying  the 
defect,  and  in  other  cases  late  discission  fails  to  effect  a 
wide  central  opening  in  the  membrane. 

(c)  In  the  remaining  cases  in  which  no  central  opacity 
would  develop  in  the  capsule,  were  it  left  in  the  eye,  no 
benefit  is  secured  by  intracapsular  extraction  of  the  lens. 
And  sometimes,  at  least  the  early  visual  result  is  poorer 
than  it  would  have  been  otherwise.  Whatever  be  the 
explanation,  we  have  been  struck  by  the  absence  of  any 
marked  superiority  in  early  visual  results*  in  Bombay 
after  the  intracapsular  operation,  as  compared  with 
ordinary  cases.  This  in  spite  of  more  or  less  after- 
cataract  frequently  left  untreated.  Maynard  had  a  more 
striking  experience  in  this  respect.     In  33  of  his  cases  the 

*  The  statement  applies  only  to  tests  made  at  the  time  of  discharge 
from  hospital.  I  have  no  knowledge  of  the  final  visual  results.  The 
vision  was  tested  usually  with  spherical  lenses  only,  and  the  pupils 
were  mostly  still  dilated  with  atropin.  But  in  a  few  cases  unsuccessful 
attempts  were  made  to  bring  the  vision  nearly  to  the  normal,  by 
correcting  the  astigmatism  and  by  the  use  of  a  stenopaic  disc. 


262  Cataract  Extraction 

two  eyes  of  the  patient  were  operated  upon,  the  one  eye 
intracapsularly,  the  other  eye  without  removal  of  the 
capsule.  In  only  7  instances  was  the  visual  result  better 
by  the  intracapsular  method,  in  10  cases  it  was  equal  in 
the  two  eyes,  and  in  15  instances  it  was  better  by  the 
ordinary  operation.  (The  remaining  case  of  the  33  was 
not  available  for  the  comparison,  as  in  this  case  the  intra- 
capsular operation  was  a  failure.) 

2.  Troubles  with  capsule — entanglements  in  the  wound, 
and  adhesions  to  cornea  and  to  iris — are,  of  course, 
impossible. 

3.  Pagenstecher*  says  that  in  early  days  the  greatest 
advantage  of  the  intracapsular  method  was  considered  to 
be  the  prevention  of  iritis,  but  that  since  the  introduction 
of  aseptic  measures  this  advantage  is  no  longer  so  evident. 
Smith  reported  only  two  cases  of  iritis  in  2,494  extractions 
in  unbroken  capsule,  whereas  in  263  operations  of  the 
same  period  in  which  capsule  was  accidentally  (after 
rupture)  or  purposely  left  behind,  iritis  occurred  in  5  per 
cent,  of  the  cases.  In  our  small  Bombay  experience  of 
extraction  of  lens  and  capsule,  the  bright  appearance  of 
the  iris  afterwards  was  often  noticed.  The  only  obvious 
explanation  is  the  absence  of  irritation  of  the  iris  by 
particles  of  lens  substance.  This  should  not  be  a  matter 
of  much  importance,  since  it  is  generally  accepted  that 
nearly  all  severe  iritis  after  operation  is  due  to  microbic 
agency.  In  Bombay  we  were  able  to  reduce  the  propor- 
tion of  closed  pupils  from  iritis  to  a  very  low  figure  (p.  270) 
after  the  ordinary  operation.  But  we  often  had  to  use 
atropin  freely  for  some  little  time.  In  cases  of  mild  in- 
fection doubtless  the  additional  strain  thrown  upon  the 
iris  by  the  irritation  of  lens  debris  may  cause  trouble. 

Opinions  are  likely  to  be  widely  divided,  for  some  years 

*  Personal  communication. 


Variations  in  Procedure,  and  their  Value    26 


o 


at  least,  upon  the  merits  and  demerits  of  extraction  in  the 
capsule  Maynard,  after  his  trial  of  it,  concluded:  "In 
face  of  these  grave  drawbacks  it  is  impossible  to  recom- 
mend the  performance  of  the  operation,  and  personally 
I  have  returned  to  the  practice  of  removing  lenses  in  their 
capsules  only  when  they  are  overripe  and  have  thick 
capsules."  He  is  at  present  employing  the  method,  how- 
ever, for  unripe  cataracts  also.*  Birdwood,  in  spite  of  an 
appalling  number  of  vitreous  losses,  was  "  gradually 
getting  convinced  that  it  should  be  the  operation  of 
election  in  nearly  all  cases."  In  Bombay  the  tendency  of 
late  years  has  been  more  and  more  away  from  the  intra- 
capsular method.  The  number  of  these  operations  has 
been  reduced  to  the  absolute  minimum. 

During  1905  and  1906,  at  the  Cowasjee  Jehangir  Hospital, 
there  were  only  twenty-four  lenses  removed  in  their  capsules 
among  1,262  flap  extractions — i.e.,  in  barely  2  per  cent,  of  the 
cases.  Four  of  these  lenses  were  forced  out  without  help  from 
the  operator,  three  by  spasm  of  the  lids,  and  one  by  vitreous 
tension.  In  four  cases  there  was  previous  dislocation  of  the 
lens,  and  in  another  subluxation.  Four  other  lenses  became 
dislocated  during  the  making  of  the  section.  In  all  the  other 
eleven  cases  the  capsulotomy  proved  insufficient,  or  the  zonule 
became  torn  by  the  pull  of  the  cystitome.  Four  of  these  eleven 
cataracts  were  Morgagnian,  and  three  others  had  been  Mor- 
gagnian, but  only  the  nucleus  and  capsule  remained.  The 
intracapsular  delivery  was  in  all  cases  obligatory  or  accidental. 
It  is,  perhaps,  interesting  to  note  in  how  small  a  proportion  of 
cataracts  the  method  is  forced  upon  one  even  in  India.  In 
Europe  and  America,  where  overripe  cataracts  are  much  less 
common,  the  proportion  should  be  still  lower. 

During  the  same  two  years  we  extracted  twenty-two 
capsules  entire  after  expulsion  of  the  lens,  with  three  vitreous 
escapes.  (Only  one  of  these  escapes  was  in  the  least  degree 
attributable  to  the  removal  of  the  capsule.)  There  were  also 
three  removals  of  portions  of  capsule,  and  five  punctures  of 

*  '  Manual  of  Ophth.  Op.,'  p.  107. 


264  Cataract  Extraction 

posterior  capsule.     In  one  of  these  latter  there  was  one  vitreous 
loss,  due  to  vitreous  tension. 

Among  the  intracapsular  extractions  the  proportion  of 
vitreous  loss  was  higher,  but  the  vitreous  accident  was 
frequently  the  cause,  and  not  the  consequence,  of  the  intra- 
capsular method  of  operation. 

The  unintentional  intracapsular  expulsion  of  Morgag- 
nian nuclei  has  been  dealt  with  on  p.  122,  the  procedure 
being  the  same  whether  the  fluid  part  of  the  lens  has  been 
evacuated  by  puncture  with  the  cystitome,  or  has  been 
slowly  absorbed  by  natural  processes  before  operation. 
Even  in  cases  where  the  zonule  has  not  been  torn  below 
by  the  pull  of  the  cystitome,  the  intracapsular  expulsion  of 
a  Morgagnian  nucleus  by  the  light  pushing  strokes  upon 
the  cornea  already  described  is  at  least  as  safe  a  pro- 
ceeding as  the  deliberate  expression  of  a  Morgagnian  lens 
in  its  unopened  capsule. 

It  is  always  possible  that  the  pull  upon  very  opaque 
anterior  capsule  with  forceps,  as  described  on  p.  112,  may 
result  in  the  partial  or  complete  intracapsular  delivery  of  a 
shrunken  overripe  lens.  A  sharp  hook  has  sometimes  been 
used  instead  of  forceps  to  pull  out  shrunken  cataracts, 
mainly  capsular.  Forceps  or  hook  must  be  employed  for 
the  withdrawal  of  such  lenses  whenever  vitreous  comes 
forward  in  front  of  the  capsule  through  a  rupture  of  the 
zonule  below.  In  some  rare  juvenile  cataracts,  chiefly 
capsular,  the  sharp  hook  may  serve  best. 

There  are  two  advantages  in  always  attempting  ordinary 
extraction.  Firstly,  it  is  not  until  the  contents  of  opaque 
capsule  have  been  removed  that  one  can  be  sure  of  the 
state  of  the  posterior  portion  of  the  membrane.  The 
lateral  displacement  of  an  anterior  plaque  of  fair  size 
brought  about  by  the  expulsion  of  the  lens,  or  its  extrac- 
tion with  iris  forceps  before  the  delivery  of  the  lens,  may 


Variations  in  Procedure,  and  their  Value    265 

be  sufficient  to  leave  the  central  pupillary  area  clear  and 
black,  the  posterior  capsule  being  possibly  quite  normal. 
In  my  experience  such  displacement  of  opaque  anterior 
capsule  is  permanent. 

Secondly,  if  the  posterior  capsule  be  found  also  more  or 
less  opaque,  or  if  the  displacement  of  a  large  anterior 
plaque  be  insufficient,  one  has  the  option  of  removing  the 
opaque  membrane  at  once,  wholly  or  in  part,  or  of  deferring 
its  treatment  until  after  the  healing  of  the  wound.  The 
latter  decision  will  be  taken  if  the  patient  have  become 
excited  and  cannot  keep  the  eye  still,  or  if  there  be  any 
sign  of  vitreous  tension.  Even  at  a  later  secondary  opera- 
tion discretion  may  suggest  the  tearing  and  displacement 
of  the  opaque  membrane  b}'  two  needles,  rather  than  to 
risk  prolapse  or  loss  of  vitreous  in  extracting  the  mem- 
brane. Ordinarily,  however,  the  immediate  extraction  of 
opaque  capsule  is  indicated,  if  the  opacity  be  situated  so 
as  to  affect  the  visual  acuteness  of  the  eye.  Thus  we 
avoid  delay  and  worry  and  the  patient's  dissatisfaction 
over  a  secondary  operation.  And  loss  of  vitreous  is  no 
more  likely  to  be  caused  in  a  quiet  patient  by  this  imme- 
diate removal  than  by  secondary  extraction.  The  most 
opaque  and  thickened  portions  of  capsule  are  often  a  little 
displaced  upwards,  and  are  thus  within  easy  reach  of  iris 
forceps  introduced  through  the  incision.  The  extraction 
of  the  membrane  is  accomplished  after  the  conjunctival 
toilet  has  been  completed,  and  usually  also  after  the  sub- 
stitution of  Desmarres'  retractor  for  the  stop-speculum. 

Elliot  *  in  ordinary  extraction  removes  with  iris  forceps  any 
tags  of  capsule  visible  after  the  chamber  has  been  washed 
clear.  He  did  this  in  thirty  out  of  200  operations.  There 
were  five  small  vitreous  losses  among  these  thirty  eyes,  and 
exactly  the  same  number  of  small  losses  among  the  remaining 

*  Ind.  Med.  Gazette^  xli  (1906),  163. 


266  Cataract  Extraction 

170  eyes.  He  considers  this  small  addition  to  the  operation  a 
much  less  dangerous  proceeding  than  expression  of  the  lens  in 
its  capsule,  "  inasmuch  as  it  is  quite  easy  to  limit  the  vitreous 
escape  by  at  once  closing  the  eye  as  soon  as  danger  threatens. 
The  lens  being  out,  this  is,  of  course,  possible." 

One  is  satisfied  with  the  least  of  the  measures  calculated 
to  provide  a  clear  central  area  for  vision,  and  to  guard 
against  impaction  of  the  capsule  in  the  wound.  The 
practical  result  should  be  as  good  as  by  intracapsular 
extraction  of  the  lens,  but  the  risk  of  large  vitreous  escape 
is  less. 

Occasionally  after  the  ordinary  delivery  of  the  lens, 
opacity  may  be  found  confined  to  the  central  area  of  the 
posterior  capsule,  in  the  form  of  a  circular  patch  or  ring. 
Without  waiting  to  inquire  into  the  nature  of  this  opacity 
— whether,  for  instance,  it  may  not  be  lens  substance 
capable  of  being  absorbed — I  have  punctured  the  capsule. 
This  puncture  might,  however,  be  more  safely  deferred  till 
the  day  before  the  patient's  discharge. 


ASEPSIS. 

The  problem  of  the  exclusion  of  exogenous  infection 
still  constitutes  one  of  the  most  vital  questions  in  cataract 
work.  For  infective  complications  varying  in  number  and 
gravity  still  occur  in  the  practice  of  every  ophthalmic 
surgeon  of  large  experience.  And  few  have  reason  to  feel 
altogether  secure  against  even  the  gravest  of  these 
accidents — destructive  irido-cyclitis  and  panophthalmitis. 
The  question  is  a  very  serious  one,  since  theoretically 
these  troubles  are  preventable.  Yet  in  the  practice  of  the 
vast  majority  of  eye  surgeons  there  is  a  definite  though 
very  small  percentage  of  total  and  irreparable  loss  of 
vision  thus  brought  about,  and  sympathetic  involvement 


Variations  in  Procedure,  and  their  Value    267 

of  the  fellow  eye  is  also  met  with.  Minor  grades  of  infec- 
tion are  not  always  clearly  recognizable,  but  nearly  all 
troublesome  iritis  and  irido-cyclitis,  and  probably  many 
quite  transient  exudations  are  attributable,  in  part  at 
least,  to  infective  origin.  We  know  that  micro-organisms 
capable  of  exciting  such  reactions  are  frequently  present 
in  the  conjunctival  sac  at  the  time  of  operation,  and  it 
would  be  strange  if  there  were  no  minor  grades  of  infec- 
tion leading  up  to  those  destructive  affections  which  are 
by  common  consent  admitted  as  due  to  bacterial  agency. 
And  often  there  is  no  other  cause  assignable  for  the  iritis 
met  with. 

The  problem  as  generally  accepted  may  be  briefly 
stated.  Modern  aseptic  surgical  principles  demand  (i)  a 
sterile  field  of  operation,  and  also  (2)  that  everything 
which  may  come  in  contact  with  the  wound  surfaces  must 
be  sterile  also.  (3)  Afterwards  the  conditions  must  be 
such  as  to  favour  early  union,  and  the  wound  must  be 
protected  against  external  influences. 

The  first  of  these  three  stipulations  cannot  be  met  fully 
in  ordinary  present-day  hospital  work.  There  is  no 
provision  made  for  the  regular  and  repeated  bacteriological 
examination  of  the  eyes — an  examination  requiring  a  con- 
siderable expenditure  of  time  in  culture  tests.  Nor  can 
patients  suffering  from  chronic  conjunctivitis,  especially 
those  coming  from  a  distance,  always  afford  time  for  the 
weeks  or,  perhaps,  months  of  treatment  required  to  free 
their  conjunctivae  from  dangerous  organisms.  Nor  can  the 
removal  of  these  organisms  be  quite  assured  by  douching 
and  swabbing  immediately  before  operation.  (It  is  un- 
necessary to  refer  again  in  detail  to  the  measures  adopted 
in  dealing  with  inflammation  of  the  tear  sac.) 

The  question  therefore  becomes  one  of  compromise. 
We  take  such  means  as  appear  to  be  indicated  for  cleans- 


268  Cataract  Extraction 

ing  the  jfield  of  operation.  But  knowing  that  the 
cleansing  is  often  imperfect,  we  try  to  avoid  transferring 
organisms  from  the  conjunctival  surface  into  the  wound 
by  instruments  and  lotions  during  operation.  We  avoid 
unnecessary  bruising  of  the  tissues,  likely  to  reduce  their 
resisting  powers,  and  we  leave  as  little  blood-clot  and  lens 
cortex  in  the  eye  as  possible — materials  which  might  serve 
as  culture  media  for  infective  organisms.  And  we  protect 
the  wound  afterwards  with  a  conjunctival  covering,  and 
avoid  as  much  as  possible  the  exposure  of  iris  or  of 
vitreous  prolapsed  in  the  wound.  Where  the  danger 
appears  especially  great  from  an  unhealthy  conjunctiva, 
or  owing  to  some  general  condition  enfeebling  the  tissues, 
there  is  the  additional  safeguard  of  the  subconjunctival 
operation. 

There  is  thus  room  for  the  exercise  of  individual  discre- 
tion and  judgment.  The  indications  are  not  exact.  We 
cannot  hope  always  to  exclude  pyogenic  bacteria,  but  we 
can  limit  their  numbers  and  perhaps  lessen  their  vitality, 
and  make  the  conditions  unsuitable  for  their  multiplica- 
tion. Experience  has  shown  that  by  the  strenuous 
application  of  such  precautionary  measures  the  evil  of  the 
imperfectly  sterilized  field  may  be  largely  neutralized.  In 
Bombay  we  claim  to  have  been  exceptionally  successful  in 
warding  off  infection,  but  the  success  has  been  ascribed 
primarily  to  a  more  effectual  cleansing  of  the  conjunctiva 
than  is  commonly  practised. 

India  affords  a  fine  field  for  conjunctival  antisepsis.  With 
the  conjunctiva  in  so  many  cases  unhealthy,  the  cleansing 
of  the  field  of  operation  becomes  by  far  the  most  important 
and  critical  item  in  our  armamentarium  for  the  defence  of 
the  wound.  One  of  the  main  lessons  to  be  drawn  from 
cataract  work  in  India  is  that  the  major  operation  can  be 
quite  safely '  performed  in  the  presence  of  slight  chronic 


Variations  in  Procedure^  and  their  Value     269 

conjunctivitis.  But  to  the  best  of  my  knowledge  safety  has 
been  attained  only  with  the  help  of  perchloride  irrigation. 
The  first  series  of  good  results  published  in  India,  un- 
broken as  regards  suppurations,  was  that  of  210  extractions 
by  Surgeon  Major  Bamber,  with  i  in  2,000  perchloride. 
It  was  reported  at  the  Indian  Medical  Congress,  1894. 
And  Smith's  Jullundur  statistics,  under  the  conditions  of 
work  there,  may  be  accepted  as  proof  of  the  value  of  the 
same  solution.  Our  Bombay  figures  afford  more  detailed 
and  conclusive  clinical  evidence  of  almost  complete  safety 
attained  by  the  use  of  a  rather  weaker  lotion  systematically 
applied.  Compared  with  clear  clinical  evidence  in  this 
question,  laboratory  findings  are  of  little  account.  And  any 
explanation  of  the  mode  of  working  is  also  of  quite  minor 
importance  to  the  establishment  of  the  essential  clinical 
fact.  But  for  this  large  figures  are  needed.  Even  in 
India,  with  the  conjunctival  danger  so  constantly  present, 
an  experience  of  at  least  a  thousand  operations  is  needed 
to  show  conclusively  the  essential  merits  or  defects  of  any 
treatment  adopted.  Only  small  differences  in  results 
under  rival  methods  of  treatment  are  to  be  expected,  when 
we  consider  the  astonishingly  low  percentage  of  failures  of 
the  pre-antiseptic  days. 

My  personal  experience  of  infection  in  hospital  cataract 
work*  under  perchloride  treatment  of  the  conjunctiva 
may  be  briefly  summed  up.  It  is  broken  up  into  periods 
by  intervals  of  leave-taking. 

The  statistics  up  to  the  end  of  January,  igoi,  were 
published  in  the  Indian  Medical  Gazette,  June,  1901, 
thus: 

With  I  in  3,000  sublimate  lotion  freely  used  there  was 

*  No  definite  records  of  my  private  work  are  available,  but  it  may 
be  stated  that  there  were  no  suppurations  at  any  time,  and  very  little 
iritis  or  irido-cyclitis. 


270  Cataract  Extraction 

a  series  of  497  extractions  completely  exempt  from  grave 
infection. 

With  the  same  fluid  rather  more  sparingly  applied,  in 
578  extractions  there  were  three  grave  primary  infections, 
irido-cyclitis  ending  in  atrophy  of  the  globe. 

Where  not  only  the  quantity,  but  in  most  instances  the 
strength  also  of  the  antiseptic  was  reduced,  panophthal- 
mitis followed  thrice  in  349  operations,  and  there  were 
seven  closed  pupils  from  iritis  or  irido-cyclitis.  (Closure 
of  some  of  these  pupils  might,  however,  possibly  have 
been  prevented  by  freer  use  of  atropin.) 

Then  followed  a  period  up  to  the  end  of  March,  1903, 
in  which  1,172  extractions  were  performed  under  the 
perchloride  treatment  as  at  present  carried  out.  There 
was  one  suppuration,  but  "  no  infective  iritis  or  irido- 
cyclitis severe  enough  to  have  resisted  energetic  treat- 
ment."* 

Finally  came  a  period  of  work  from  October,  1904,  to 
April,  1907.  It  included  1,655  extractions.  There  were 
no  suppurations,  and  the  only  complications  recognizable 
as  severe  infective  results  at  the  time  of  discharge  from 
hospital  were  two  cases  of  iritis  closing  the  pupils,  prob- 
ably susceptible  of  remedy  later  by  artificial  pupil.  There 
were  also  the  two  untreated  cases  of  sympathetic  disease 
described  in  Chapter  V,  in  which  loss  of  sight  was  attri- 
butable largely  to  neglect,  and  a  third  case  of  loss  of  sight 
from  chronic  cyclitis. 

We  can  claim,  therefore,  a  near  approach  to  perfection 
in  final  results  in  this  latest  series  of  operations,  so  far  as  un- 
controlled infective  inflammation  is  concerned.  But  it  was 
only  towards  the  end  that  we  felt  fairly  safe  in  this  respect. 
For,  besides  the  three  losses,  there  were,  until  towards 

*  '  The   Practical   Details   of   Cataract    Extraction,'   2nd   edition, 
1903,  pp.  53  and  54. 


Variations  in  Procedure,  and  their  Value     271 

the  end,  numerous  early  exudations,  which  we  regarded  as 
partly  at  least  representing  infective  agency.  And  during 
this  period  we  had  also  one  destructive  irido-cyclitis  in 
private  practice.  The  minor  manifestations  of  reaction 
became  decidedly  less  frequent  latterly.  And  it  was  this 
which  inspired  confidence  that  the  graver  accidents  might 
be  entirely  warded  off,  and  that  we  could  hope  to  go  on 
operating  indefinitely  without  meeting  with  suppurations 
or  uncontrollable  irido-cyclitis.  But  this  recent  improve- 
ment was  not  brought  about  by  any  change  in  the  treat- 
ment of  the  conjunctiva.  It  followed  the  adoption  (i)  of 
the  mouth-screen  during  operation,  and  (2)  of  enhanced 
precautions  in  connexion  with  intraocular  irrigation. 
Except  for  the  variations  in  the  perchloride  treatment 
mentioned,  these  changes,  both  recent,  were  the  only  ones 
made  during  the  whole  of  the  periods  under  review,  which 
could  have  had  any  influence  upon  infective  complications.* 

Considering,  therefore,  the  large  number  of  unhealthy 
conjunctivas  in  the  eyes  operated  upon,  the  influence  of 
the  sublimate  douching  must  have  been  very  great  in 
enabling  us  to  attain  to  the  results  just  recorded.  And  the 
figures  themselves  afford  evidence  of  insufficient  protection 
when  less  lotion  or  weaker  lotion  was  used. 

The  very  bad  bacteriological  condition  of  the  Bombay 
conjunctivae,  and  the  effect  of  the  perchloride  in  removing 
organisms  from  them,  were  directly  shown  by  the  examina- 
tion of  a  consecutive  series  of  fifty  cataract  cases  just 
before  operation. 

The  details  of  the  research  were  published  in  The  Ophthalmo- 
scope, iv  (1906),  674.     In  twenty-four  of  the  fifty  conjunctivae 

*  Another  change  which  should  be  mentioned  here  was  the  fairly 
frequent  performance  of  subconjunctival  operations.  But  this  merely 
enabled  us  to  operate  in  cases  which  we  should  otherwise  have 
refused  for  the  time  being.  Our  infections  have  never  come  when 
most  feared. 


272  Cataract  Extraction 

there  were  few  or  no  bacteria  except  diptheroid  bacilli  (possibly 
all  xerosis  bacilli)  before  or  after  the  sublimate  douching.  In 
all  the  remaining  cases  other  organisms  were  fairly  plentiful 
or  decidedly  numerous.  They  comprised  white  staphylococci 
alone  in  five  cases.  Most  of  the  other  conjunctivae  contained 
more  than  one  variety  of  organism  in  addition  to  the  sapro- 
phytic diphtheroids.  Besides  white  cocci,  some  of  them  possibly 
pathogenic,  coloured  cocci  were  fairly  numerous,  including 
Staphylococcus  aureus  and  citreus,  and  others  unidentified,  and 
probably  in  some  cases  incompletely  separated.  Morax- 
Axenfeld  diplo-bacilli  were  found  in  five  cases,  and  they  were 
numerous  in  two  of  the  five.  Numerous  pneumococci  were 
found  once,*  and  numerous  streptococci  once.  In  four  of 
these  twenty-six  cases  the  effect  of  the  perchloride  douching 
appeared  to  be  insufficient,  several  colonies  being  grown  from 
each  conjunctiva  afterwards.  But  in  the  remainder  the  effect 
of  the  treatment  was  definite,  and  possibly  sufficient.  Either 
no  growth  was  obtained  afterwards  or  only  very  few  colonies — 
a  single  colony  in  nine  instances,  two  colonies  in  three  cases, 
and  four  colonies  once.  These  results  were  obtained  ten 
minutes  after  the  perchloride  douching — i.e.,  immediately  after 
the  cocain  instillation.  They  do  not  include,  therefore,  the 
further  effect  which  would  be  derived  from  the  supplementary 
small  douching  nearly  always  added  immediately  before 
operating.  If  the  result  had  been  tested  after  operation,  a 
more  complete  clearance  of  organisms  could  have  been 
anticipated. 

It  is  worthy  of  mention  that,  though  hundreds  of  colonies  of 
diphtheroid  bacilli  were  grown  from  some  conjunctivae  before 
irrigation,  not  a  single  one  was  obtained  after  irrigation. 
Diplo-bacilli  seem  also  easy  of  removal ;  no  growth  was 
obtained  from  the  treated  conjunctivae.  Staphylococci,  on  the 
other  hand,  in  general  proved  more  resistant,  and  this  was  the 
case  whether  they  were  present  in  large  or  small  numbers. 
This  resistance  suggests  frequent  embedding  of  the  cocci 
rather  deeply  in  the  conjunctival  epithelium.  In  several  cases 
a  delay  of  a  day  or  two  was  noted  in  the  appearance'  of  the 
colonies  grown  from  the  conjunctivae  after  treatment,  suggest- 
ing some  direct  action  of  the  antiseptic  upon  the  bacteria. 

*  In  a  conjunctiva  normal  except  for  slight  injection  and  roughness. 


Variations  in  Procedure,  and  their  Value    273 

It  seems  probable  that  in  similar  tests  carried  out  years 
ago  by  others  sufficient  time  was  not  allowed  for  the 
action  of  the  perchloride  to  manifest  itself.  Bach*  even 
found  mechanical  cleansing  with  salt  solution  more 
efficacious.  A  germicide  was  looked  for.  And  when 
perchloride  was  found  ineffective  in  this  respect,  like  other 
antiseptics  as  applied  to  the  conjunctiva  before  operation, 
it  was  thought  to  be  useless,  and  even  harmful,  because 
irritating.  Perchloride  is  of  use  here  mainly  because  of 
its  irritant  and  coagulative  action  upon  the  conjunctiva. 
It  excites  a  secretion  of  mucus,  in  which  micro-organisms 
are  entangled  and  washed  away,  and  microbes  also  prob- 
ably become  imprisoned  in  the  epithelium  which  undergoes 
coagulation-necrosis.  Finally,  in  cases  where  much  lotion 
is  used,  it  may  directly  attack  the  vitality  of  the  organisms. 
A  sterile  field  of  operation  is  by  no  means  assured,  but  of 
this  we  had  already  been  made  aware  by  our  clinical 
results. 

With  danger  so  frequently  present  and  so  obvious  in 
the  Indian  conjunctiva  it  seems  strange,  at  first  thought, 
that  it  can  be  so  constantly  avoided.  But  the  very 
frequency  of  the  danger  is  the  patient's  salvation,  for  it 
has  led  to  a  lavish  and  regular  employment  of  the  necessary 
precautionary  measure.  In  European  and  American 
practice  the  danger  is  possibly  greater,  because  it  is 
insidious  and  comparatively  rare.  Precaution  is  unneces- 
sary in  the  large  majority  of  cases,  and  in  cases  where  it  is 
required  the  signs  indicative  of  the  necessity  may  be  not 
very  obvious.  In  any  case  the  tendency  is  to  minimize 
uncustomary  irritative  measures,  from  fear  of  exciting 
reaction.  Considering  the  very  good  results  which  have 
been  obtained  with  simple  mechanical  cleansing,  surgeons 
accustomed   to   working   upon    normal    conjunctivae   are 

*  Ref.  Haab,  '  Operative  Ophthalmology,'  p.  41. 

18 


274  Cataract  Extraction 

naturally  loth  to  use  any  irritating  chemical.  But  they 
must  be  quite  sure  of  obtaining  the  good  results.  And 
recognizing  the  great  help  derived  from  perchloride  in 
India,  they  should  not  be  reluctant  to  make  free  use  of 
this  protection  in  cases  where  there  is  any  suspicion  of 
danger.  Since  we  are  working  in  the  dark  to  a  large 
extent,  the  precautions  must  err  rather  in  direction  of 
excess  if  uniform  safety  is  to  be  attained. 

In  deciding  upon  the  relative  advantages,  or,  rather, 
the  applicability  of  chemical  and  of  simple  mechanical 
cleansing  of  the  conjunctiva,  it  is  in  no  sense  a  question  of 
antisepsis  versus  asepsis.  In  no  case  is  the  solution  used 
after  the  operation  has  been  begun.  Elliot  (Madras)  is 
the  only  surgeon  of  large  experience  in  India  who  has 
reported  any  extensive  trial  of  simple  mechanical  cleansing 
of  the  conjunctiva  before  operation.  He  sedulously  treated 
cases  of  corijunctivitis  beforehand,  accommodating  the 
patients  with  sleeping  space  on  the  hospital  floor  when 
necessary.  But  the  results  were  not  quite  good  enough, 
and  the  method  has  been  replaced  by  perchloride  treat- 
ment exactly  as  practised  in  Bombay,  combined  with  free 
subsequent  swabbing  of  the  conjunctiva.*  Elliot  is  now 
strongly  in  favour  of  this  plan  of  treatment,  and  feels,  with 
me,  that  suppuration  ought  never  to  occur.  He  has  had  a 
thousand  consecutive  extractions  with  only  one  suppura- 
tion. And  this  one  catastrophe  was  in  a  case  where  the 
lacrymal  sac  had.  been  imperfectly  excised. 

In  Bombay  we  regarded  the  skin  of  the  lids  and  surrounding 
parts,  and  even  the  lid  margins,  as  almost  outside  the  field  of 
operation.  So  far  as  the  lid  borders  are  concerned,  this  was 
unsound,  for  we  found  it  necessary  to  express  the  secretion 
from  the  Meibomian  glands,  in  order  that  some  of  the  secretion 
should  not  be  floated  up  from  the  lid  borders  to  the  neigh- 

*  Personal  communication.  Report  to  appear  shortly  in  the 
/n(f.  Med.  Gazette. 


Variations  in  Procedure,  and  their  Value     275 

bourhood  of  the  wound  during  intraocular  irrigation.  It  is, 
therefore,  obvious  that  micro-organisms  might  be  also  thus 
carried  up  to  the  wound  in  irrigating  fluid.  We  were  always 
careful,  however,  to  wipe  away  the  expressed  Meibomian 
secretion  with  perchloride  swabs. 

The  second  requirement  laid  down  for  the  avoidance  of 
contamination  of  the  wound  applies  to  instruments, 
lotions,  the  lid  borders,  and  the  surgeon's  and  the 
attendant's  saliva.  There  is  no  excuse  for  imperfect 
sterilization  of  instruments  beforehand.  But  during 
operation  considerable  watchfulness  is  required  to  avoid 
soiling  an  instrument  before  its  entry  into  the  wound,  by 
unnecessary  contact  with  the  conjunctival  surface,*  still 
more  with  the  lid  margin.  And  in  repeated  introduction 
of  the  same  instrument  into  the  eye  one  must  remember 
to  cleanse  it  afresh.  Sufficient  has  been  said  already  with 
regard  to  the  dangers  of  unnecessary  instrumentation  and 
especially  of  intraocular  irrigation ;  and  one  objection  to 
excessive  instrumentation  is,  perhaps,  the  possibility  of 
diminishing  the  resistance  of  the  tissues  by  slight  trau- 
matism. The  risk  of  contact  between  the  lid  borders  and 
the  edges  of  the  wound  is  the  chief  objection  to  separation 
of  the  lids  by  finger  traction. 

It  stands  as  a  confession  of  weakness  and  of  ignorance, 
that  a  prolonged  operation  must  be  admitted  practically 
as  a  danger  in  itself.  Since  we  do  not  work  in  a  sterile 
field,  and  since  we  are  often  uncertain  both  of  the  source 
and  of  the  exact  mode  of  conveyance  of  the  organisms  into 
the  wound,  prolongation  of  the  period  of  exposure  to  con- 
tamination must  enhance  the  risks.  The  benefits  of 
rapidity  and  simplicity  of  procedure  are  seen  in  work  such 
as  Trousseau's.!     Introducing  only  one  instrument,  the 

"'■  Note  the  suggestion  made  on  p.  192  with  regard  to  the  possible 
value  of  the  conjunctival  flap  in  this  respect, 
t  La  Clinique  Ophtal.,  November  25,  1905. 

18—2 


276  Cataract  Extraction 

knife,  into  the  eye,  he  has  had  only  2  per  cent,  of  iritis 
and  no  suppurations,  though  no  special  treatment  of  the 
conjunctiva  had  been  adopted,  and  though  cortical  debris 
must  have  been  left  in  the  eye  frequently.  Smith's  com- 
parative success  at  Jullundur  is  also  thought  to  be  partly 
attributable  to  the  introduction  of  but  the  one  instrument 
within  the  globe.*  In  analyzing  results  the  operative 
technique  must  be  considered  as  a  whole.  In  our  Bombay 
work  with  more  prolonged  exposure  and  more  elaborate 
detail,  probably  considerably  more  care  was  needed  to 
avoid  infection,  quite  apart  from  the  bad  average  state  of 
the  conjunctiva. 

For  the  protection  of  the  wound  against  secondary  in- 
fection during  the  healing  period  the  value  of  a  scleral 
incision  and  a  conjunctival  covering,  especially  of  the  com- 
plete covering  provided  by  Czermak's  operation,  cannot  be 
disputed;  otherwise,  a  smooth  section f  and  close  coapta- 
tion of  the  wound  surfaces  are  designed  especially  to  secure 
rapid  healing.  In  addition,  measures  to  preclude  reopening 
of  the  wound  (either  by  occlusive  bandage  or  '  modified 
open  '  dressing),  and  prompt  excision  of  uncovered  pro- 
lapsed iris,  are  the  chief  safeguards.  But  the  danger  at 
this  period  would  appear  to  be  a  minor  one  compared 
with  the  risks  during  operation,  for  results  appear  to  vary 
chiefly  with  the  measures  adopted  for  protection  during 
operation.  Nature  provides  for  early  union  by  fairly  close 
apposition  of  the  wound  surfaces  without  the  need  of 
sutures,  and  by  maintenance  of  the  parts  at  rest,  protected 
against  outside  influences  by  the  upper  lid. 

■■'■   The  Ophthalmoscope,  v  (1907),  558. 

t  Hotta  {Clin.  Monats.  f.  Augen,  September,  1905)  published  an 
account  of  some  interesting  experiments  upon  the  infection  of  corneal 
wounds  in  rabbits  with  human  saliva,  showing  the  influence  of  the 
character  of  the  wound.  There  was  no  infection  of  thirty  smoothly- 
cut  incisions  with  a  Graefe's  knife,  and  invariable  infection  in  thirty 
'  pocket '  wounds. 


Variations  in  Procedure,  and  their  Value    277 

An  attempt  has  been  made  by  Rogman*  to  heighten  the 
resistance  of  the  tissues  against  microbic  invasion  by  the 
injection  of  5  to  10  cubic  centimetres  of  a  mixture  of  anti- 
streptococcus  serum  (Menzer)  and  anti-pneumococcus  serum 
(Rohmer).  It  was  employed  for  an  iridectomy  in  a  patient 
with  dacryocystitis,  and  for  cataract  extraction  in  a  patient 
with  ozaena.  Louis  Dor  administers  2  grammes  of  potassium 
iodide  the  night  before  operation  with  the  same  idea  of  reducing 
the  risk  of  infective  inflammations. 

Endogenous  infection,  appealed  to  as  an  excuse  for  bad 
results,  is  a  refuge  of  the  destitute.  Apparently  undoubted 
cases  of  destructive  metastatic  inflammation  of  the  eye  have 
been  reported  after  cataract  extraction.  Hildebrandt  f  reported 
a  case  due  apparently  to  acute  rheumatism,  and  Wopfner  I  one 
due  to  pneumonia  from  Friedlander's  pneumo-bacillus.  It  is, 
however,  certain  that  infection  from  within  is  not  to  be  feared 
in  healthy  people.  It  is  well  that  suppuration  at  a  distance, 
ulcers,  fistulae,  etc. — possible  starting  points  of  pyaemia — should 
be  treated  before  operating. 

The  general  trend  of  recent  work  is  to  fix  the  responsi- 
bility for  infective  accidents  very  definitely  upon  the 
surgeon.  In  the  not  distant  future  we  may  find  this 
responsibility  recognised  by  the  patient,  and  possibly  up- 
held in  law  courts.  No  exceptional  skill  is  required  in  the 
application  of  the  scheme  of  defence.  Simply  the  measures 
must  be  complete  in  every  detail,  and  carried  out  with 
extreme  care. 

RESULTS. 

Bad  Results  may  be  due  to  : 

I.  Defective  Operation,  particularized  in 

(a)  Incorrect  Method;  especially  (i)  inefficient  measures 

for  securing  asepsis,  or  (2)  inherent  defects  in  the  operative 

technique  adopted. 

*  Bu//.  de  la  Societe  beige  (TOphtal.,  Mai,  1904. 
f  Beitr.  zur  Augen.,  viii  (1893),  33. 
%  Kl.  Monats.f.  A.,  xliv  (1906),  i,  386. 


278  Cataract  Extraction 

(6)  Want  of  Skill  on  the  part  of  the  surgeon,  or  less 
commonly,  of  his  assistant.  Dexterity  in  operating  is 
made  up  of  three  elements,  rising  in  order  of  importance 
thus :  (i)  A  steady  hand ;  (2)  a  light  hand,  combining  a 
fine  muscular  sense  with  a  delicate  sense  of  touch ;  and 
(3),  the  most  important,  experience. 

Nos.  1  and  2  are  best  developed  by  training  apart  from 
actual  operative  work.  Though  No.  i  conduces  particularly 
to  pretty  operations,  No.  2  is  more  helpful  in  getting  over  diffi- 
culties and  preventing  accidents.  Very  nimble  fingers  are  not 
required.  No.  3  means  a  prompt  recognition  of  the  particular 
features  of  each  case,  and  of  difficulties  and  dangers  as  they 
arise.  Practical  experience  can  only  to  a  limited  extent  be 
replaced  by  reading  and  by  seeing  others  operate,  and  by 
operating  upon  dead  eyes. 

(c)  Want  of  Control  on  the  part  of  the  patient.  This 
may  render  the  best  efforts  of  the  skilled  hand  unavailing ; 
but  the  discerning  operator  may  very  often  judge  before- 
hand when  trouble  from  this  cause  is  likely  to  be  en- 
countered, and  lessen  the  dangers  by  suitable  precautions 
(p.  168). 

II.  Eyes  more  or  less  unfit  for  operation.  The 
surgeon  may  have  failed  to  realize  the  conditions,  or  he 
may  have  accepted  risks  under  the  pressure  of  circum- 
stances, or  he  may  have  rightly  decided  to  expect  only  a 
poor  result,  where  no  better  was  obtainable.  The  attain- 
ment of  even  poor  vision  may  prove  to  have  been 
impossible,  the  data  available  not  having  given  sufficiently 
definite  indications  beforehand. 

Our  Bombay  results,  as  regards  infection,  have  been 
already  given.  The  following  is  an  Analysis  of  Visual 
Results  of  the  flap  extractions  performed  during  1905  and 
1906,  as  seen  at  the  time  of  discharge  from  hospital : 


Variations  in  Procedure,  and  their  Value     279 

Total  Operations,  1,262. 

Bad  Results  =  vision  nil,  or  moving  bodies  only,  22=i'7per 
cent. 

Of  these  bad  results,  three  were  of  a  purely  temporary 
nature,  and  accounted  for  by  cortex  or  blood  covering  the 
pupillary  area.  Twelve  others  were  due  to  pre-existing  disease 
of  the  eye,  including  old  irido-cyclitis,  vitreous  opacity,  chor- 
oidal atrophy,  optic  atrophy,  glaucoma,  corneal  opacity  (one 
case,  together  with  cortex  left  behind).  There  were  seven 
failures  due  to  the  operation  itself  =  0-5  per  cent.  Three  of 
these  failures  were  due  to  expulsive  haemorrhage,  one  to  large 
fundus  haemorrhage  (not  expulsive),  one  to  (?)  haemorrhagic 
detachment  of  choroid  (a  large  spontaneous  loss  of  vitreous 
occurred  during  operation).  The  remaining  two  failures  were 
due  to  iritis. 

These  are  the  only  two  which  can  be  considered  definitely 
preventable,  and  even  they  were  not  certainly  irremediable. 
There  was  a  prospect  of  later  improvement  by  iridotomy,  for 
which,  however,  the  patients  never  returned. 

If,  however,  we  add  what  we  know  of  the  later  results,  we 
have  to  record  three  total  losses — two  cases  of  irido-cyclitis, 
which  also  destroyed  the  fellow  eyes  by  sympathetic  involve- 
ment, and  a  case  of  chronic  cyclitis,  with  probable  detachment 
of  retina.  The  sympathetic  cases  are  mentioned  again  on 
p.  287. 

The  four  certain  losses  by  intraocular  haemorrhage  all 
occurred  during  1906.  This  was  a  very  heavy  proportion, 
judging  from  our  earlier  experience.  One  of  the  eyes  was 
glaucomatous — secondary  glaucoma,  due  to  traumatic  cataract, 
with  subluxation  of  the  lens.   Another  eye  was  highly  myopic. 

Poor  and  Fair  Results  =  vision  less  than  /^.  Total  78  =  6*2 
per  cent. 

In  igo6  these  results  were  considerably  fewer  than  in  1905, 
including  only  twenty-seven  out  of  the  seventy-eight  cases,  or 
4*2  per  cent,  of  the  total  operations  for  the  year. 

The  comparatively  poor  results  of  1905  are  largely  accounted 
for  by  the  fact  that  the  practice  of  early  needling  had  not  then 
been  instituted  at  the  C.  J.  Hospital.  There  were  eighteen 
defective  visual  results  attributable  to  after-cataract  in  1905, 
and  only  four  such  in  1906  (due  to  cortex  alone  or  with  blood 
remains).     In  eight  cases  in  1905  and  in  two  cases  in  1906  the 


2  8o  Cataract  Extraction 

cause  of  the  defective  sight  was  not  ascertained.  This  was 
due  to  neglect  by  the  assistants  of  the  hospital  rule  that 
cylinders  were  to  be  used  in  all  cases  where  spherical  lenses 
failed  to  give  /^  vision.  The  rule  was  that  cases  which  still 
failed  with  cylindrical  lenses  were  to  be  examined  by  me. 

The  remaining  sources  of  imperfect  vision  nearly  all  dated 
from  before  operation.  They  included :  Corneal  opacity, 
17  cases;  vitreous  opacities,  5;  choroidal  atrophy,  3;  glau- 
coma, 4;  occluded  pupil,  4;  traumatic  cataract,  2;  squint,  i. 
Other  causes  were  connected  with  the  operation :  Iritis,  2 ; 
detachment  of  retina,  2  ;  prolapse  of  vitreous,  i  ;  prolapse  of 
vitreous  and  of  iris,  i  ;  (?)  fundus  haemorrhage,  i.  Three  other 
patients  appeared  to  be  simply  of  too  defective  intelligence  to 
respond  to  the  tests. 


CHAPTER   V 
AFTER-COMPLICATIONS 

The  infective  processes  and  non-infective  reactions — Various  forms 
of  corneal  opacity — Exfoliation  of  corneal  epithelium — Ante- 
flexion of  the  corneal  flap — Filamentous  keratitis — Conjuncti- 
vitis— Acute  dermatitis — Spastic  entropion — Prolapse  and  incar- 
ceration of  iris — Prolapse  and  loss  of  vitreous — Impaction  of 
capsule  —  Intraocular  haemorrhage  —  Delayed  union  and  re- 
opening of  the  wound — Transient  detachment  of  the  choroid — 
Mental  disturbance  —  Flatulent  distension  of  the  abdomen  — 
Secondary  glaucoma— After-cataract — Detachment  of  retina. 

THE  INFECTIVE  PROCESSES  AND  NON- 
INFECTIVE  REACTIONS. 

The  Infective  Processes  constitute  by  far  the  most  im- 
portant departures  from  the  normal  course  of  events  after 
operation.  They  are  the  most  frequent  cause  of  partial  or 
complete  failure  to  restore  sight,  and  often  also  of  greater 
or  less  destruction  of  the  essential  tissues  of  the  eye. 
Besides  the  actual  entrance  of  pathogenic  bacteria  of 
varying  degrees  of  virulence,  factors  influencing  the  grade 
and  extent  of  inflammatory  reaction  are  those  affecting 
the  vitality  of  the  tissues.  The  danger  of  operating  upon 
the  eyes  of  patients  in  the  later  stages  of  diabetes  or 
nephritis  is  well  recognized.  And  one  can  scarcely  expect 
the  tissues  of  patients  presenting  extreme  anaemia  from 
any  cause  to  withstand  infective  organisms.  But  ex- 
perience shows  that  only  such  readily  recognizable  con- 
stitutional  conditions   predispose    markedly  to    pyogenic 

281 


282  Cataract  Extraction 

invasion.  Locally  the  resistance  to  bacterial  invasion 
may  doubtless  be  lowered  by  excessive  traumatism,  but 
this  factor  is  rarely  evident.  The  open  door  provided 
for  the  later  admission  of  infective  material  by  prolapse  of 
iris  or  of  vitreous  has  been  already  alluded  to,  and  is 
mentioned  again  later.  The  mere  bursting  open  of  the 
wound  after  closure  is  claimed  to  admit  infection  some- 
times. Owing  to  the  reduced  intraocular  pressure  after 
evacuation  of  the  chamber,  organisms  are  supposed  to  be 
sucked  into  the  eye. 

The  most  severe  examples  of  the  effects  produced  are 
grouped  as  Suppurations.  Starting  either  as  corneal 
wound  infections,  or  as  general  intraocular  invasions,  they 
culminate  in  panophthalmitis.  The  deep  infections  soon 
give  rise  to  ring  abscess  of  the  cornea.  The  signs  and 
symptoms  are  generally  pronounced  within  twenty-four 
hours.  There  is  severe  pain,  much  inflammatory  swelling 
of  conjunctiva  and  eyelids  (that  of  the  margin  of  the  upper 
lid  being  well  marked),  with  semi-purulent  conjunctival 
discharge  lying  about  the  borders  of  the  lids.  The  edges 
of  the  wound  may  or  may  not  be  infiltrated,  yellowish, 
and  swollen.  The  corneal  surface  is  often  steamy,  and 
the  iris  and  pupil  are  covered  with  dirty  lymph.  In  spite 
of  all  treatment  the  inflammatory  conditions  rapidly  in- 
tensify. Fibrinous  and  purulent  exudation  accumulates  in 
the  anterior  and  posterior  chambers,  and  in  the  vitreous, 
distending  the  eyeball  and  opening  the  wound  ;  and 
where  the  wound  itself  is  directly  invaded,  suppurative 
destruction  of  the  cornea  spreads  from  it.  These  most 
intense  cases  are  quite  hopeless  from  the  start ;  but  there 
are  other  deep  infections  which  begin  rather  less  acutely, 
and  hang  for  some  days  apparently  in  the  balance.  And 
there  are  rare  destructive  inflammations,  which  begin 
later,  possibly  several  days  after  operation,  in  which  the 


After^CompIications  283 

infection   gains    access   to    the   eye    in   some   way   after 
operation. 

In  one  of  our  suppurations  everything  went  well,  with  easily 
dilated  pupil  and  but  little  injection  of  the  eye,  until  the  case 
was  transferred,  five  days  after  operation,  to  another  ward, 
where  some  patients  were  being  treated  for  conjunctivitis, 
preparatory  to  cataract  extraction.  The  next  day  the  eye 
became  inflamed,  and  in  a  few  days  had  advanced  to  panoph- 
thalmitis. 

Less  intense  infections  are  seen  as  severe  Irido-cyclitis. 
One  may  be  in  doubt  at  first  whether  the  case  may  not 
end  in  panophthalmitis.  Short  of  this,  many  cases  end 
equally  badly  so  far  as  vision  is  concerned — in  atrophy 
of  the  globe.  And  there  may  be  sympathetic  implication 
of  the  other  eye.  Still  other  inflammations  respond  to 
treatment,  and  subside  with  retention  of  useful  vision  in 
the  eye.  Early  pain,  complained  of  spontaneously  by  the 
patient  at  the  surgeon's  first  visit,  on  the  day  after  opera- 
tion, is  a  particularly  threatening  symptom.  On  inspec- 
tion there  may  be  already  a  trace  of  yellowish  white 
exudation  seen  at  the  margins  of  the  pupil  and  coloboma, 
and  the  surface  of  the  iris  presents  a  very  blurred 
appearance. 

A  lower  grade  of  intensity  is  seen  in  the  cases  classed 
usually  as  Iritis  simply,  though  doubtless  the  ciliary  body 
is  also  more  or  less  involved  in  the  process.  Though  not 
very  threatening  in  appearance  at  first,  these  inflamma- 
tions may  persist  in  spite  of  treatment,  ending,  perhaps,  in 
closed  pupils.  Still,  in  treated  cases,  at  least,  the  eyeballs 
do  not  usually  soften.  There  is  a  prospect  of  later  restora- 
tion of  more  or  less  useful  vision  by  secondary  operation. 
The  only  two  cases  of  sympathetic  ophthalmia,  which  we 
know  to  have  happened  after  our  Bombay  operations, 
followed  upon  inflammations  classed  as  simple  iritis  (one 


284  Cataract  Extraction 

case  was  not  even  regarded  at  the  time  as  iritis),  but  the 
inflammations  were  neglected. 

The  symptoms  usually  set  in  several  days  after  opera- 
tion. Possibly,  as  a  rough  rule,  the  later  the  onset  the 
milder  the  inflammation.  There  is  pain,  perhaps  more  at 
night,  and  usually  lacrymation,  slight  lid-swelling,  and 
more  ciliary  congestion  than  usual.  But  in  feeble,  sickly 
persons  there  may  be  a  quiet  outpouring  of  lymph,  with 
very  mild  or  no  symptoms.  I  noticed  an  alarming  amount 
of  quiet  exudation,  but  rapidly  reabsorbed,  in  a  few  anaemic 
patients  operated  upon.  In  our  experience  some  degree 
of  muddiness  of  iris  and  of  pupil  is  to  be  found  in  the 
majority  of  cases  on  the  day  following  operation.  And 
probably  vigorous  treatment  with  atropin  and  mercury, 
begun  at  once,  prevents  many  inflammations  from  develop- 
ing. Of  the  many  early  threatening  appearances  which  have 
resolved  under  treatment,  it  has  been  impossible  to  decide 
how  far  the  signs  of  exudation  have  represented  infective 
agency,  and  how  far  simply  reaction  to  traumatism,  irrita- 
tion from  lens  debris,  etc.  We  attributed  our  comparative 
exemption  from  closure  of  the  pupil  due  to  iritis  largely 
to  exceptionally  vigorous  after-treatment,  and  not  solely  to 
the  measures  for  guarding  the  wounds  from  infection. 

In  our  work  focal  illumination  after  twenty-four  hours 
showed  comparatively  few  clear  and  active  pupils,  with 
bright  iris.  There  were  degrees  of  reaction  culminating 
in  a  pupil  largely  occupied  by,  and  in  thickened  iris 
partly  hidden  by,  lymph  mixed  with  blood  remains  and 
lens  debris.  And  it  often  took  several  days'  free  use  of 
atropin,  morning  and  evening,  to  obtain  fair  dilatation 
of  the  pupil.  In  general  the  exudation  was  not  added  to 
upon  the  following  days.  On  the  contrary,  absorption 
took  place,  though  it  was  sometimes  slow  and  incom- 
plete.    And  pain  and  lacrymation  remained  absent.     We 


After'CompIications  285 

thought  that  some  of  these  Early  Exudations,  even  though 
quite  transient,  were  due  probably  to  the  action  of  micro- 
organisms, in  part  at  least.  For  it  was  impossible  to 
distinguish  them  in  the  first  day  or  two  from  other  cases 
in  which  pyogenic  action  was  shown  by  persistence  of 
exudation  and  the  onset  of  symptoms.  Certainly,  however, 
infective  agency  was  not  a  very  frequent  source  of  this 
early  transient  exudation. 

That  the  exudation  was  due  mainly  to  irritation  from 
minute  particles  of  lens  substance  left  behind,  was  shown 
by  its  almost  sure  absence  after  intracapsular  extraction 
and  after  ordinary  extraction  of  Morgagnian  cataract.* 
The  rarity  of  iritis  after  the  intracapsular  operation  has  been 
already  referred  to.  It  appears  to  apply  to  infective  iritis. 
If  this  be  so,  the  only  obvious  explanation  is  that  con- 
tributory factors  commonly  play  a  large  part  in  the 
development  of  infective  inflammation.  Cortical  debris 
by  irritating  the  iris  probably  leads  to  a  deposit  of  fibrin, 
in  which  organisms  may  develop,  and  the  lens  substance 
itself  may  provide  a  suitable  culture  medium  for  pyogenic 
bacteria.  Also  possibly  the  additional  strain  placed  upon 
the  absorptive  power  of  the  eye  may  handicap  the  tissues 
in  their  struggle  with  micro-organisms.  Among  other  local 
causes  of  early  iritic  reaction  may  be  mentioned :  (i)  a 
varying  degree  of  traumatism,  especially  bruising  of  the 
iris  in  squeezing  the  lens  through  a  small  section,  also 
accidental  pull  upon  the  iris  through  movement  of  the  eye 
or  through  badly  cutting  scissors,  etc. ;  (2)  prolonged 
irrigation  of  the  anterior  chamber,  especially  with  fluid  at 
an  unsuitable  temperature ;  and  (3)  reflex  disturbance 
from  an  exceptional  degree  of  surface  irritation  by  the 

*  Yet  beware  of  Morgagnian  '  milk  '  left  behind  the  iris.  In  two 
simple  extractions  we  had  early  inflammatory  glaucoma  set  up  by  it, 
through  exclusion  of  the  pupil. 


286  Cataract  Extraction 

perchloride.  Also  (4)  injury  to  the  eye  during  sleep, 
through  ill-fitting  bandage  or  screen ;  and  possibly  (5)  slight 
reaction  from  adrenalin- constriction  of  blood-vessels,  if 
excessive.  Albuminuria,  with  some  oedema  about  the 
ankles,  and  considerable  anaemia,  must  be  mentioned  here 
as  a  constitutional  condition  exceedingly  likely  to  lead  to 
early  exudation  of  lymph.  Less  likely  causes  are  diabetes, 
gout,  rheumatism,  etc  The  purely  transient  exudations 
are  of  importance  only  in  so  far  as  they  form  posterior 
synechise,  preventing  dilatation  of  the  pupil,  and  more  or 
less  permanent  after- cataract.  It  is  scarcely  necessary  to 
remark  that  the  formation  of  posterior  synechise  is  very 
common  after  cataract  extraction  quite  apart  from  the 
occurrence  of  iritis.  Adhesions  form  readily  between  the 
edges  of  the  capsular  opening  and  the  pupillary  margin,  and 
are  particularly  common  after  combined  extraction  at  the 
projecting  angles  between  pupil  and  coloboma.  Some  are 
due  to  imperfect  absorption  of  blood-clot. 

In  a  few  of  these  early  cases  of  muddy  iris  and  pupil, 
after  about  three  days  the  anterior  chamber  is  found 
largely  occupied  with  *  spongy '  or  *  gelatinous  '  exudate. 
That  is  to  say,  a  semi-translucent  deposit  covering  pupil 
and  iris  has  begun  to  shrink.  Perfectly  clear  iris  can  be 
seen  at  the  periphery  at  one  part,  but  elsewhere  the  iris, 
pupil,  and  coloboma  are  covered.  The  prognosis  in  these 
cases  is  good.  The  contraction  of  the  exudate  progresses 
rapidly  under  treatment,  and  any  needful  discission  may 
often  be  performed  in  little  over  a  fortnight  from  the  time 
of  operation. 

Other  exudations  fail  to  clear  up,  and  symptoms  develop 
— pain,  lacrymation,  etc. — indicative  of  Non-Infective 
Iritis.  Some  degree  of  inflammation  appears  to  be  some- 
times kept  up  mainly  or  entirely  by  lens  matter.  Though  a 
large  quantity  of  cortical  matter  may  often  be  left  behind, 


After-Complications  287 

with  no  effect  whatever  upon  the  iris,  this  is  when  the 
pupil  is  at  once  dilated.  Probably  then  the  capsule  is 
for  the  most  part  interposed  between  the  iris  and  the  lens 
substance.  But  sometimes  sufficiently  rapid  dilatation  of 
the  pupil  is  not  secured,  and  the  lens  cortex  lies  in  direct 
contact  with  the  iris.  The  more  irritating  lens  substance 
appears  to  be  that  of  the  more  advanced  cataracts.  The 
worst  in  our  experience  is  the  milk  of  Morgagnian 
cataracts,  but  it  is  only  rarely  that  any  of  this  is  left  in  the 
eye.  Elliot  (Madras)  finds  that  lens  cortex  which  swells 
up  and  "  assumes  a  gelatinous  appearance  "  is  but  little 
prone  to  set  up  adhesions,  but  that  it  is  otherwise  with 
stiff,  unyielding  cortex.  Some  slight  cases  of  iritis  may  be 
due  to  injury  by  the  patient's  fingers,  etc.  Other  per- 
sistent mild  inflammations  appear  to  be  kept  up  sometimes 
by  venous  congestion,  from  constant  coughing  or  from 
straining  at  micturition.  Also  constitutional  taints,  such 
as  are  capable  of  originating  attacks  of  iritis  apart  from 
operation — gout,  rheumatism,  diabetes,  nephritis,  etc. — 
may  be  expected  to  give  trouble  at  times.  Again,  the 
operation  may  serve  to  awaken  old  mischief. 

In  one  case  in  which  we  operated  upon  an  eye  with  occluded 
pupil,  and  in  which  a  needling  was  performed  afterwards, 
chronic  iritis  followed,  with  the  formation  of  three  probably 
tubercular  nodules  (see  *  After- Cataract '). 

Rarely  corneal  wound  infections  remain  localized.  The  ac- 
companying reaction  is  only  very  moderate,  and  the  suppu- 
rative process  can  be  arrested  by  suitable  treatment.  I 
remember  one  such  case  in  which  suppuration  destroyed  only 
a  small  portion  of  the  corneal  flap,  not  extending  to  its  posterior 
surface. 

Sympathetic  Ophthalmia. — The  only  two  cases  in  which 
we  know  that  this  complication  followed  cataract  extrac- 
tion performed  by  us  in  Bombay  require  mention  here.  One 
patient  was  discharged  a  month  after  operation  seeing  /„  with 
a  spherical  lens.     But  she  was  still  being  treated  with  atropin 


288  Cataract  Extraction 

drops  nine  times  a  day,  and  with  mercury  internally.  She 
insisted  upon  going  home,  though  advised  to  stay  longer.  The 
extraction  had  been  *  simple,'  and  followed  by  prolapse  of  iris, 
excised  the  next  day.  She  returned  four  and  a  half  months 
after  the  operation  with  pupil  and  coloboma  completely  covered 
with  pigmented  lymph.  There  was  no  ciliary  injection  remain- 
ing, however,  and  the  eye  was  not  soft,  so  that  there  appeared 
to  be  a  possibility  of  later  restoration  of  some  vision.  The 
fellow  eye,  sound  at  the  time  of  discharge  from  hospital,  was 
now  practically  destroyed  by  untreated  inflammation. 

The  other  patient  was  discharged  twenty  days  after  a 
combined  extraction,  seeing  -^^  with  a  spherical  lens.  Atropin 
and  mercury  had  been  used  in  full  amounts  for  a  week  only. 
After  that  time  the  mercury  was  omitted,  and  the  drops  used 
less  frequently.  The  patient  came  back  nearly  three  months 
after  operation  with  both  eyes  quite  hopeless. 

In  both  of  these  instances  there  appears  to  be  little  doubt 
that  the  evil  result  might  have  been  averted  under  more 
prolonged  observation  and  treatment.  In  the  second  case 
there  was  no  anticipation  whatever  of  active  mischief  when 
the  patient  was  allowed  to  go  home. 

A  case  of  sympathetic  inflammation  ending  in  blindness  has 
been  reported  by  Zentmayer  "  (Philadelphia),  following  panoph- 
thalmitis after  cataract  extraction. 

Late  Infections  occurring  months  or  years  after  opera- 
tion, through  fistulous  and  cystoid  scars,  have  earned  an 
evil  repute  with  respect  to  their  proneness  to  cause  sympa- 
thetic ophthalmia.  We  attributed  our  almost  complete 
(apparent)  exemption  from  these  results  to  the  broad  con- 
junctival coverings  over  such  incarcerations  of  iris  and  of 
capsule  as  were  left  in  the  wounds.  I  only  remember  one 
late  infection.  It  was  an  acute  case,  iritis  with  hypopyon. 
But  it  subsided  rapidly  under  treatment. 

Treatment. — It  is  a  safe  rule  in  all  cases  where  the  iris  is 
not  perfectly  bright  and  active  on  the  day  following  opera- 
tion, to  endeavour  to  obtain  immediate  dilatation  of  the 

*  At  the  Amer.  Med.  Assoc,  Ophth.  Section,  1905. 


After-Complications  289 

pupil.  Where  there  is  much  muddiness,  as  much  atropin 
is  instilled  as  seems  likely  to  be  borne  without  con- 
stitutional symptoms.*  We  commonly  instilled  the  drops, 
4  grains  to  the  ounce,  four  or  five  times  in  the  morning, 
with  five-minute  intervals,  and  a  similar  number  of  times 
in  the  evening.  In  these  cases  mercury  should  always  be 
given  at  once  also,  either  by  inunction  or  by  the  mouth, 
or  both.  And  it  is  perhaps  advisable  to  begin  with  a  dose 
of  calomel,  3  to  5  grains,  partly  to  act  as  a  purge.  Possibly 
in  threatening  cases  intramuscular  injections  should  be 
given  for  the  first  few  days,  after  Schirmer.t  His  experi- 
ence shows  the  great  value  of  mercury  in  the  case  of 
infected  wounds,  both  in  controlling  the  local  reaction  and 
in  preventing  sympathetic  involvement  of  the  fellow  eye. 
In  Bombay  we  had  emphatic  evidence  of  the  usefulness  of 
the  drug  in  this  respect.  After  a  few  days,  when  the 
bandaging  is  stopped,  dionin  may  be  of  assistance  also, 
increasing  the  action  of  the  atropin  and  helping  in  the 
absorption  of  lymph.  Sodium  salicylate,  60  to  90  grains 
daily,  has  been  recommended  in  place  of  mercury.  But 
there  is  not  the  same  evidence  in  its  favour.  It  is  said 
that  if  sympathetic  ophthalmia  should  follow  in  spite  of 
salicylate  treatment,  it  will  be  benign  (Lindahl). 

In  the  more  threatening  reactions  subconjunctival  injec- 
tions should  be  used  early.  The  benefit  derived  from 
them  is  often  quite  noticeable.  It  is  recommended  that 
if  a  subconjunctival  injection  cannot  be  made  on  account 
of  chemosis  in  acute  inflammations,  the  needle  should  be 
inserted  through  the  outer  part  of  the  lower  lid  near  the 
orbital  margin.  Bourgeois  (Rheims)  injects  |  c.c.  of  i  in 
1,000  cyanide  of  mercury,  and  repeats  it  several  times, 
night  and  morning,  if  necessary.     In  Bombay  we  have 

*  The  assistants  must  be  made  responsible  that  general  symptoms 
are  not  occasioned  by  the  solution  passing  down  into  the  nose, 
t  A.f.  O.,  liii,  I. 

19 


290  Cataract  Extraction 

been  satisfied  with  the  more  ordinary  i  in  2,000  solution 
on  the  few  occasions  upon  which  we  have  needed  injec- 
tions, and  have  inserted  about  15  minims.  Moissonier* 
(Tours)  found  common  salt  injections  more  efficacious 
than  cyanide  injections  in  one  case. 

In  all  cases  of  definite  iritis  or  irido-cyclitis  presumably 
infective,  the  administration  of  mercury  should  be  pushed 
(unless  there  is  some  constitutional  contra-indication)  to 
*  touch  the  gums  '  within  a  week. 

In  all  severe  infections  the  coverings  of  the  eye  are 
removed,  and  the  conjunctival  sac  irrigated  with  per- 
chloride  lotion,  i  in  5,000,  twice  a  day.  Hot  fomentations 
are  applied  if  they  relieve  pain. 

The  insertion  of  sterile  iodoform  in  powder,  and  in 
small  discs  (soloids)  and  rods,  into  the  anterior  chamber 
has  been  tried  in  severe  irido-cyclitis  and  in  corneal 
wound  infections.  It  was  first  used  experimentally  by 
Ostwalt  (1897),  and  has  been  recommended  by  Haab 
and  others.  The  benefit  derived  has  not  been  very 
marked,  and  the  treatment  has  not  been  very  generally 
followed.  Cohnt  used  iodoform  pencils  in  four  infected 
eyes  with  no  noticeable  result. 

If  the  wound  surfaces  be  infiltrated  and  panophthal- 
mitis threaten,  it  is  said  that  the  process  may  possibly  be 
arrested  by  cauterizing  the  infiltrated  surfaces  freely. 
Kuhnt  has  suggested  scraping  of  the  surfaces  and  covering 
with  a  strip  of  conjunctiva.  Irrigation  of  the  anterior 
chamber  with  warm  cyanide  or  salt  solution  is  also 
recommended. 

Evisceration  is  held  to  be  the  correct  procedure  in  pan- 
ophthalmitis or  suppurative  irido-cyclitis  ;  enucleation  for 
atrophy   following   upon    plastic   inflammation.     In    the 

*  Tenth  Internat.  Congress  at  Lucerne,  1904. 
t  Zeitschr.  f.  A.,  xiii,  i,  31. 


After^CompIications  2  9 1 

milder  inflammations  which  respond  to  treatment  it  is 
important  to  keep  the  pupil  widely  dilated  as  long  as  any 
ciliary  injection  remains.  And  the  administration  of 
mercury  is  continued  also.  A  watch  must  be  kept  for  the 
possible  onset  of  secondary  glaucoma. 

Late  secondary  infections  are  treated  upon  the  same 
lines  as  the  early  ones. 


VARIOUS   FORMS   OF   CORNEAL   OPACITY. 

The  striated  corneal  opacity  known  as  striped  keratitis 
is  seen  the  day  after  operation  as  parallel  vertical  grey 
lines  in  the  upper  half  of  the  cornea,  running  down  from 
the  (upper)  section.  The  streaks  have  been  shown  to 
represent  ridges  on  the  posterior  surface  of  the  cornea, 
due  to  oedema,  and  are  commonly  the  result  of  bruising  of 
the  cornea  in  squeezing  the  lens  through  a  rather  small 
wound,  or  by  the  frequent  introduction  of  instruments. 
They  have  been  attributed  also  to  tight  bandages,  and 
to  intraocular  irrigation.  The  affection  usually  clears  off 
within  a  week  without  treatment. 

Less  often  a  diifuse  cloud  of  opacity  forms,  apparenth' 
of  similar  origin  to  the  striated  condition,  if  one  may 
judge  by  its  position  and  equally  transient  character. 
Sometimes  a  central  patch  of  corneal  haziness  develops, 
with  or  without  streaks  connecting  it  with  the  wound. 
These  central  patches  occurred  particularly  often  in  our 
practice  after  subconjunctival  extraction  by  Czermak's 
method,  and  were  obviously  due  to  damage  of  the  endo- 
thelium of  the  cornea  in  the  somewhat  difficult  expulsion 
of  the  lens  The  area  of  opacity  was  nearly  always  broken 
up  by  fine,  clear  interlacing  lines  into  a  number  of 
smaller  areas  giving  rise  to  an  appearance  very  like  that 
of  broken-up  soft  lens  cortex  lying  in  the  anterior  chamber. 

19 — 2 


292  Cataract  Extraction 

It  would  seem  likely  that  the  stripes  running  from  the 
wound  indicate  bruising  of  the  wound  surfaces  rather  than 
injury  to  the  posterior  surface  of  the  cornea,  judging  from 
the  different  appearance  of  the  opacities  unconnected  with 
the  wound. 

There  are  other  less  common  diffuse  opaque  areas  (not 
broken  up  into  sections)  which  appear  rather  later  and 
tend  to  be  permanent,  and  which  represent  contact  keratitis. 
They  are  sometimes  seen  in  cases  of  retarded  union  of 
the  wound,  from  prolonged  contact  between  lens  capsule 
and  cornea.  The  capsule  and  the  pupillary  margin  of  the 
iris  may  form  adhesions  to  the  cornea. 

There  are  other  fine  lines  to  be  seen  fairly  often,  at  the 
time  of  discharge  from  hospital,  on  the  posterior  surface 
of  the  cornea  unconnected  with  the  wound.  I  have  not 
seen  them  described  as  yet.  They  are  so  fine  that  they 
require  the  corneal  loupe  and  focal  illumination  for  their 
examination,  and  so  they  may  readily  escape  detection. 
Many  of  them  crossing  about  the  centre  of  the  cornea, 
they  may  serve  to  reduce  the  visual  acuteness.  They 
are  fine,  double-contoured,  grey  lines,  mostly  slightly  curved, 
of  variable  length,  but  ending  within  the  corneal  cir- 
cumference. They  thus  closely  resemble  ruptures  of 
Descemet's  membrane,  but,  unlike  them,  appear  to  be 
only  temporary,  disappearing  within  a  few  months.  I 
think  we  have  seen  them  most  numerous  in  cases  where 
there  had  been  earlier  central  corneal  opacity.  They  are 
very  variable  in  number  and  direction  ;  both  horizontal 
and  vertical  lines  may  be  present  together.  I  once 
noticed  fine  vertical  lines  on  the  posterior  surface  of  the 
cornea  at  the  close  of  the  operation. 

There  still  remains  to  be  mentioned  the  permanent 
opacity  which  results  from  the  introduction  of  sublimate 
lotion  or  other  feebly  caustic  chemical  solution  into  the 


After-Complications  293 

anterior  chamber.  Our  unfortunate  experience  with  sub- 
Hmate  solution  in  Bombay  has  been  already  described 
sufficiently. 

Exfoliation  of  Corneal  Epithelium. 

A  rough  corneal  surface  from  irregular  shedding  of  epithelium 
is  very  common  after  operation  under  combined  adrenalin  and 
cocain.  Even  under  cocain  alone  it  is  frequent  unless  care  be 
taken  to  prevent  drying  of  the  surface  before  and  during  opera- 
tion. It  is,  perhaps,  induced  also  by  much  friction  upon 
the  cornea  with  lens  expressors.  It  is  not  a  matter  of  any 
importance. 

Anteflexion  Or  Eversion  of  the  Corneal  Flap 

must  be  very  rare  as  an  occurrence  taking  place  after  closure  of 
the  lids  and  the  application  of  the  usual  bandage.  Oatman* 
reported  such  a  case,  found  at  the  first  dressing,  forty-eight 
hours  after  operation.  The  conjunctiva  was  much  contracted 
by  scarring,  and  it  was  thought  that  the  pull  from  the  lower 
fornix  must  have  opened  the  wound  sufficiently  for  the  flap  to 
be  caught  against  the  border  of  the  upper  lid.  The  flap  was 
replaced  by  manipulation  with  a  probe  under  the  closed  lid. 
It  united  without  inflammatory  complications,  and  became 
highly  vascularized.  Glaucoma  followed.  See  also  Elliot's 
case  mentioned  on  pp.  306  and  311. 

Bending  downwards  of  the  conjunctival  flap  over  the  cornea 
is  a  rare  occurrence.  In  one  of  our  cases  the  flap  appeared  to 
be  pushed  down  by  swollen  ocular  conjunctiva.  The  dis- 
placement recurred  repeatedly.  The  conjunctival  flap  is  more 
likely  to  be  carried  down  by  escaping  vitreous. 

Filamentous  Keratitis 

is  given  by  Knapp  as  a  complication  seen  occasionally  "by 
the  end  of  the  second  week."  I  have  seen  it  a  few  times,  and 
attribute  it  to  too  free  perchloride  irrigation  before  operation. 
It  occurred  in  one  of  our  cases  where  the  operation  had  to 
be  deferred  after  only  the  puncture  and  counter-puncture  had 
been  made.  Four  fine  filaments  had  formed  on  the  upper 
part  of  the  cornea  two  days  later.     There  was  also  a  patch 

*  Arch,  of  Ophth.^  xxv  (19&6),  481. 


294  Cataract  Extraction 

of  pseudo-membrane  on  the  upper  tarsal  conjunctiva,  and 
similar  material  binding  together  the  swollen  folds  in  the 
lower  fornix  (such  a  condition  as  leads  to  the  formation  of 
conjunctival  'bridges'  and  'pouches').  The  filaments  lasted 
as  long  as  the  conjunctival  membrane.  Had  the  operation 
been  completed,  it  would  have  been  impossible  to  evert  the 
upper  lid  early,  and  the  condition  of  the  lower  fornix  might 
have  escaped  recognition  also.  Thus  the  association  between 
the  corneal  and  conjunctival  conditions  would  probably  have 
escaped  notice,  and  the  cause  of  the  corneal  complication 
would  not  have  been  recognized. 

Some  years  ago  a  patient  of  mine  with  ripe  cataract  in  one 
eye  had  almost  constant  filamentary  keratitis  in  that  eye,  and 
very  little  in  the  fellow  eye.  After  trials  of  many  forms  of 
treatment,  we  were  able  to  control  the  condition  sufficiently 
for  operation  to  be  successfully  performed,  by  the  daily  appli- 
cation of  I  per  cent,  silver  nitrate  solution  to  the  everted  lids 
for  some  little  time  before  operation.  Curiously,  he  remained 
free  from  the  corneal  affection  until  lately,  when  the  second 
cataract  was  ripening.  The  filaments  then  reappeared,  chiefly 
in  the  cataractous  eye,  and  recurred  constantly  until  the  lens 
was  extracted  from  that  eye  also.  Since  then  I  believe  the 
corneae  have  remained  unaffected. 


Conjunctivitis. 

Inflammatory  reaction  to  perchloride  irrigation  is  marked 
by  swelling  of  the  conjunctiva  and  of  the  eyelids.  But  there 
is  little  discharge  except  in  the  rare  cases,  such  as  that 
above  mentioned,  in  which  probably  the  whole  thickness 
of  epithelium  is  destroyed  over  some  portion  of  the  con- 
junctival surface,  giving  rise  to  a  pseudo-membrane.  As 
already  stated,  there  is  often  difficulty  in  deciding  to  what 
extent  simple  swelling  is  due  to  filtration  oedema,  and  to  what 
extent  due  to  inflammatory  reaction. 

Persistent  post-operative  conjunctivitis  is  commonly  asso- 
ciated with  the  presence  of  staphylococci.  Abelsdorf  and 
Neumann*  found  the  Diplococcus  albicans  tardissimus  in  three 
cases.     It  may  be  a  continuation  of  a  chronic  conjunctivitis 

*  A.  f.  A.,  (1900)  xlii. 


After-Complications  295 

imperfectly  cured  before  operation,  and  may  have  been 
aggravated  by  bandaging,  atropin  drops,  etc. 

Whenever  there  is  discharge,  the  patient  should  be  en- 
couraged to  keep  the  eyes  open  as  much  as  possible. 

Acute  Dermatitis. 

Apart  from  atropin  irritation,  we  have  seen  a  few  cases 
of  acute  inflammation  of  the  skin  of  the  lids  and  neigh- 
bouring parts.  They  were  evidently  due  to  the  perchloride 
used  in  washing  the  parts.  The  complication  is  well  recog- 
nized as  indicating  an  idiosyncrasy.  Yet  in  one  of  our 
cases  both  eyes  were  operated  upon  (at  an  interval),  and 
the  complication  only  occurred  on  the  one  side.  Evidently 
the  washing  must  have  been  more  thorough  on  this  occasion. 
In  our  cases  there  was  no  particularly  noticeable  associated 
conjunctival  reaction.  The  sharply  defined  reddened  area  of 
skin  had  an  erysipelatous  appearance.  The  lids  were  quite 
stiff  and  swollen,  and  could  scarcely  be  separated.  Obviously 
bandaging  was  unnecessary.  In  two  patients  numerous  bullae 
formed.  And  in  one  of  these  cases  the  discharge  from  the 
bullae  caused  an  extension  backwards  of  the  inflammation  over 
the  scalp,  and,  entering  the  conjunctiva,  produced  a  hypopion, 
evidently  by  infection  through  the  imperfectly  healed  wound. 
The  pupil  dilated  easily,  however,  and  the  final  result  was 
quite  satisfactory. 

Spastic  Entropion 

of  the  lower  lid  in  old  people,  promoted  by  the  bandage,  may  very 
rarely  necessitate  an  early  removal  of  the  bandage,  with,  per- 
haps, the  application  of  strapping  to  the  lower  lid  for  its  relief. 


PROLAPSE  AND  INCARCERATION  OF  IRIS. 

Prolapse  or  hernia  of  iris  is  the  bete  noire  of  simple 
extraction ;  incarceration  is  a  complication  mainly  confined 
to  the  combined  operation.  The  base  or  pillar  of  a 
coloboma  may  enter  the  wound  in  a  single  layer,  other- 
wise a  knuckle  or  fold  of  iris  becomes  impacted. 

Prolapse  is  generally  found  at  the  first  dressing,  twenty- 


296  Cataract  Extraction 

four  hours  after  operation.  An  onset  a  few  days  later*  is 
seen  rather  more  after  operation  with  conjunctival  flap; 
the  development  may  be  very  gradual  where  the  sclero- 
corneal  wound  is  open  under  the  conjunctival  flap.  In  any 
case  an  early  incarceration  may  enlarge  later.  The  dis- 
tinction between  a  visible  incarceration  and  a  minute 
prolapse  is  almost  inappreciable.  Impaction  between  the 
deeper  portions  of  the  wound  surfaces  only  is  scarcely 
distinguishable  clinically  from  mere  adhesion  to  the  cornea 
in  the  line  of  the  wound.  Even  a  small  prolapse  may 
include  the  whole  breadth  of  the  iris  from  base  to  pupil, 
the  protrusion  being  correspondingly  prominent.  On  the 
other  hand,  wider  entanglements  in  the  wound,  including 
only  the  base  of  the  iris,  may  remain  but  little  elevated. 
After  simple  extraction  the  greater  portion  of  the  incision 
may  become  occupied  by  a  very  large  prolapse. 

The  onset  of  the  complication  may  be  marked  by  more 
or  less  pain.  I  once  saw  spontaneous  retraction  of  a 
minute  prolapse. 

I  found  the  prolapse  possibly  an  hour  after  the  first  dressing 
of  the  eye  by  the  hospital  assistant.  The  patient  was  removed 
to  the  operating  room,  and  cocain  instilled.  The  prolapse, 
which  had  not  been  seen  by  the  assistant,  and  had  therefore 
occurred  at  the  time  of  the  dressing  or  afterwards,  had  then 
disappeared,  and  the  pupil  was  round  and  central. 

Spontaneous  reduction  has  been  recorded  after  much  longer 
intervals. 

Causes. — (i)  Prolapse  of  iris  is  the  result  which  we  fear 
most  from  reopening  of  the  wound  after  closure.  The 
wound  may  be  burst  open  by  external  influence,  as  (a)  by  any 
accidental  blow  or  pressure  or  friction  upon  the  eye,  by  the 
patient's  finger  or  by  a  pressure  bandage,  for  instance; 

*  Rarely,  when  the  heaHng  of  the  wound  is  imperfect,  prolapse  of 
iris  may  occur  considerably  later,  as  in  the  case  mentioned  on  p.  309. 


After^CompIications  297 

(6)  by  pressure  of  the  lids ;  (c)  by  movements  of  the  globe. 
Also  by  coughing,  sneezing,  vomiting,  straining  at  stool 
or  at  micturition,  or  in  other  muscular  effort. 

Even  with  the  lid  muscle  at  rest  the  elastic  tension  of  the 
lids  exerts  some  pressure,  variable  in  degree,  upon  the  globe, 
as  may  be  seen  especially  in  '  slack  eyes  '  during  operation. 
It  may  be  sufficient  in  itself  to  cause  slight  gaping  of  a  cataract 
incision  placed  at  the  lower  corneal  margin.  This  pressure 
may  be  greatly  increased  by  contraction  of  the  orbicularis, 
especially  in  prominent  eyes.  By  sudden  violent  closure  of 
the  lids,  a  wound  at  the  upper  corneal  margin  may  be  forced 
open,  because  the  pressure  upon  the  globe  is  increased 
unevenly.  The  pressure  of  the  marginal  bundles  of  the 
orbicularis  as  they  come  together  is  applied  below  the 
horizontal  meridian  of  the  cornea.  The  inequality  of  the 
pressure  is  greatest  when  the  elastic  tension  of  the  lids  is 
least,  as  in  some  old  people.  Similar  contraction  of  the 
orbicularis  is  excited  by  any  pain  in  the  eye,  also  by  a  tight 
bandage,  and  is  said  to  occur  in  coughing,  sneezing,  etc. 
Uneven  pressure  upon  the  eye  by  the  lower  lid  only  may  be 
brought  about  also  in  dressing  the  eye  if  the  upper  lid  alone  be 
raised. 

Extreme  movements  of  the  globe,  especially  in  the  vertical 
direction,  occurring  only  with  the  eyes  opened,  tend  to 
separate  the  wound  margins  by  the  pull  of  the  muscles  and 
by  increase  of  ocular  tension  through  the  pressure  of  the 
muscles.  Opening  of  the  wound  is  thus  sometimes  seen 
during  operation. 

Increase  of  tension  may  also  possibly  occur  by  venous 
stasis  in  coughing,  straining,  etc. 

On  any  sudden  reopening  of  the  wound  after  simple  extrac- 
tion, as  insisted  upon  by  Fuchs  and  Swanzy,  the  iris  may  be 
carried  into  the  wound  by  the  aqueous  lying  behind  it  in  the 
posterior  chamber,  for  the  fluid  makes  directly  for  the  wound 
by  the  shortest  route,  instead  of  passing  around  through  the 
pupil  into  the  anterior  chamber.  A  narrow  coloboma  well  up 
to  the  base  of  the  iris  is  sufficient  to  guard  against  this.  But 
even  with  the  chambers  empty,  on  any  increase  of  tension 
together   with   gaping   of  the   incision,    the   pressure   of   the 


298 


Cataract  Extraction 


vitreous  may  suffice  to  force  iris  into  the  wound.  This  is  well 
seen  during  operation  in  cases  of  so-called  vitreous  tension. 
The  vitreous  itself  may  or  may  not  become  prolapsed  with  the 


Where  the  deep  incision  remains  gaping  under  a  con- 
junctival flap,  the  iris  sometimes  slowly  finds  its  way 
between  the  wound  surfaces. 

In  simple  extraction  damage  to  the  sphincter  of  the 
pupil  by  the  knife  or  by  the  passage  of  the  lens  is  a  great 
predisposing  factor.  An  active  pupil  is  usually  an  effective 
safeguard.  And  in  combined  extraction  removal  of  an 
unnecessary  large  portion  of  the  pupillary  zone  of  the  iris 
with  its  sphincter  muscle — whether  by  scissors  or  acci- 
dentally by  the  knife — predisposes  to  prolapse,  as  also  does 
imperfect  replacement  of  the  pillars  of  the  coloboma. 
This  replacement  may  be  impracticable  when  the  iris  is 
carried  into  the  incision  by  escaping  vitreous. 

The  swelling  of  lens  cortex  left  behind  the  upper  part  of 
the  iris  is  held  to  be  at  least  a  contributory  cause  of 
prolapse. 

Some    Percentages    of  Prolapse   reported   by  Various 
Operators. 


After  Simple 

After  Combined 

Number  of  Cases 

Author. 

Operation. 

Operation. 

reported  upon. 

Little          1 

19*00 

— 

106 

— 

o"3o 

322 

Swanzy 

— 

113 

354 

Schweig-ger 

7-90 

— 

451 

Galezowski 

0-50 

— 

200 

Drake  Brockman... 

1 1 79 

— 

1,169 

Moorfields  results    / 
(Marshall)         ...t 

13-87 

• — 

267 

087 

1,091 

My  own  results     ... 

8-37 

— 

490 

Consequences. — The  most  serious  effect  of  a  prolapse 
which  is  allowed  to  remain  is  a  permanent  liability  to 


After-Complications  299 

bacterial  invasion  of  the  eye.  But  the  degree  of  risk 
undoubtedly  varies  with  the  exposure  of  the  protruded  iris. 
It  may  He  bare,  or  may  be  partly  or  entirely  covered  with 
conjunctival  flap.  We  noticed  in  Bombay  that  with  a 
large  exposure  of  iris  there  was  often  some  iritis  from 
the  first,  the  enlarged  and  distorted  pupil  being  at  once 
occupied  by  a  thin  layer  of  lymph.  This  was,  perhaps, 
especially  to  be  expected  in  Indian  practice  owing  to  the 
general  prevalence  of  chronic  conjunctivitis.  When  the 
prolapse  was  quite  small  or,  if  large,  completely  covered  by 
conjunctiva,  the  iris  and  pupil  generally  remained  per- 
fectly clear  throughout.  And  from  a  large  experience  of 
subconjunctival  prolapse  intentionally  produced  in  the 
treatment  of  chronic  glaucoma,  we  learnt  that  a  large 
degree  of  permanent  protection  against  infection  was 
afforded  by  the  conjunctival  covering  over  the  weak  scar. 
Though  a  bare  prolapse  becomes  soon  covered  by 
epithelium,  the  layer  is  possibly  thinner  than  that  persist- 
ing from  a  covering  conjunctival  flap,  and  therefore  more 
likely  to  become  abraded.  Thus  the  remains  of  uveal 
tissue  may  become  exposed,  there  being  no  conjunctival 
and  subconjunctival  connective  tissue  beneath  the  epi- 
thelium. Hence  the  occurrence  of  late  infective  inflam- 
mations, either  acute  and  suppurative,  possibly  ending  in 
panophthalmitis,  or  chronic  and  insidious,  and  possibly 
more  serious  than  the  acute  cases,  leading  to  sympathetic 
involvement  of  the  fellow  eye. 

An  exposed  knuckle  of  iris  becomes  quickly  covered 
with  lymph  and  adherent  to  the  surfaces  of  the  opening 
through  which  it  has  escaped.  As  the  union  becomes 
consolidated  the  extruded  iris  gradually  loses  much  of  its 
pigment,  becoming  changed  into  more  or  less  pervious 
fibrous  tissue.  Quite  small  protrusions  often  flatten  down 
within  a  few  months  without  cicatrizing  firmly.     A  more 


300  Cataract  Extraction 

or  less  fistulous  or  filtering  track  forms,  through  which 
some  aqueous  passes,  often  reducing  the  ocular  tension 
slightly. 

As  a  final  result  of  a  small  subconjunctival  protrusion 
there  is  more  or  less  oedema  of  the  neighbouring  con- 
junctiva. Often  a  sharply  defined  pale,  transparent  vesicular 
patch  of  conjunctiva,  a  filtration  area,  develops  over  and 
around  the  remains  of  iris,  which  is  seen  as  a  dark  under- 
lying point.  The  patch  is  2  or  3  millimetres  or  more  in 
breadth,  more  or  less  unevenly  elevated,  and  in  dark  and 
yellow-skinned  races  generally  sharply  outlined  by  the 
dark  colour  of  the  surrounding  conjunctiva,  intensified  by 
an  accumulation  of  pigment  washed  out  of  the  vesicular 
area.  This  represents  the  typical  subconjunctival  fistula. 
There  are  other  smaller  opaque  grey  elevations,  formed 
evidently  by  the  union  of  the  conjunctival  covering  with 
the  loop  of  iris.  Some  of  these,  evidently  filtering  more 
freely  than  the  rest,  present  dark  centres  bordered  by 
narrow  whitish  rims  (of  sodden  epithelium  ?). 

Large  prolapses  commonly  persist  without  appreciable 
diminution  in  size,  changing  to  a  greyish  colour  by  loss  of 
pigment  and  by  union  with  overlying  conjunctiva.  The 
neck  of  the  protrusion,  however,  evidently  tends  to  con- 
tract as  regards  its  internal — not  its  external — surface. 
For,  on  laying  open  the  cavity  of  the  staphylomatous  pro- 
minence, there  may  be  no  immediate  drainage  of  aqueous 
from  the  anterior  chamber.  The  term  '  cystoid  cicatrix '  is 
applied  sometimes  to  these  staphylomatous  scars,  at  other 
times  to  smaller  prolapses  with  vesicular  conjunctival 
coverings.  If  used  at  all,  the  term  should  be  restricted  to 
the  former  class  of  case. 

Displacement  and  distortion  of  the  pupil  result  from  the 
drawing  of  the  iris  upwards,  the  degree  of  these  defects 
varying  with  the  width  and  elevation  of  the  prolapse.     A 


After^CompIications  301 

small  but  prominent  prolapse,  including  the  whole  breadth 
of  iris,  may  draw  the  pupil  quite  up  to  the  cicatrix, 
narrowing  it  also.  Increase  in  width  of  the  pupil  with  less 
complete  displacement  may  result  from  a  wider  inclusion 
of  the  base  of  the  iris.  In  the  case  of  a  very  exten- 
sive prolapse  the  lower  margin  of  the  greatly  stretched 
pupil  may  rise  well  above  the  horizontal  meridian  of 
the  cornea.  I  have  had  to  perform  iridotomy  on  this 
account. 

Depending  mainly  upon  the  extent  of  the  incision 
occupied  is  the  degree  of  forward  displacement  of  the 
corneal  flap  and  consequent  astigmatism.  A  quite  localized 
protrusion  of  the  whole  breadth  of  iris  may  have  little  or 
no  effect  upon  the  corneal  curvature,  while  an  extended 
inclusion  of  the  base  of  the  iris  may  cause  considerable 
flattening.  The  astigmatism  is  often  irregular,  and  there- 
fore only  partly  corrected  by  cylindrical  lenses.  By  a  very 
large  prolapse  the  upper  part  of  the  cornea  may  be  bent 
forward  instead  of  backward,  a  fine  transverse  grey  line  on 
the  back  of  the  cornea  marking  the  lower  limit  of  the 
abnormal  curvature. 

A  prominent  staphyloma  is  not  only  very  disfiguring, 
but  tends  to  keep  up  chronic  conjunctival  irritation. 
The  bulbar  conjunctiva  on  either  side  of  the  eleva- 
tion is  no  longer  cleansed  by  the  movement  of  the  lids 
over  it. 

In  ophthalmic  literature  references  to  secondary 
glaucoma  resulting  from  prolapse  and  incarceration  of  iris 
are  so  frequent  as  to  convey  an  exaggerated  impression  of 
the  closeness  of  the  connexion.  I  have  rarely  known 
high  tension  together  with  inclusion  of  iris  visible  exter- 
nally. The  tendency  is  to  the  development  of  low  tension 
by  filtration  of  aqueous  through  the  weak  scar.  Possibly 
in   some  cases  this    may  be    prevented    by  impaction  of 


302  Cataract  Extraction 

vitreous*  together  with  iris  in  the  wound.  In  other  cases 
the  high  tension  may  be  only  temporary.  In  treating 
chronic  glaucoma  by  subconjunctival  prolapse  I  found 
that  in  some  eyes  a  period  of  high  tension,  lasting  possibly 
two  or  three  months,  supervened  before  filtration  was 
established.  But  these  were  eyes  in  which  the  iris  was 
tough  and  rigid  from  old  glaucomatous  changes. 

Treatment. — If  a  small  prolapse  be  seen  very  shortly 
after  its  onset,  replacement  with  a  spatula,  followed  by 
eserin  instillation,  is  probably  indicated.  But  when  the 
prolapse  is  found  simply  at  the  daily  dressing  of  the  eye, 
and  the  iris  has  been  exposed  in  the  conjunctival  sac 
possibly  for  hours,  its  reduction  is  objectionable,  lest 
adherent  infective  organisms  be  carried  into  the  eye. 
Immediate  excision  is  the  only  correct  treatment.  It 
is  often,  however,  by  no  means  easy.  The  congested  loop 
of  iris  is  hyperaesthetic,  and  is  rendered  only  partially 
insensitive  by  cocain.  ■  The  use  of  a  stop-speculum  and 
fixation  of  the  eye  are  both  inadmissible,  lest  loss  of 
vitreous  be  brought  about. 

It  is  generally  considered  necessary  or  advisable  to 
perform  the  small  operation  under  general  anaesthesia  ; 
and  this  is  the  great  drawback  to  the  treatment.  The 
risk  of  loss  of  vitreous  or  possibly  of  intraocular  haemor- 
rhage from  vomiting  after  the  anaesthetic  must  be  con- 
sidered. But  I  have  never  found  general  anaesthesia 
necessary.  Adrenalin  is  instilled  twice,  and  is  followed 
by  cocain,  4  per  cent,  solution,  four  times  at  somewhat 
prolonged  intervals,  so  that  twenty  minutes  in  all  is  taken 
up.  If  there  were  still  any  trouble  from  pain  excited  by 
seizure  of  the  iris,  the  application  of  a  few  crystals  of 

*  Otherwise,  how  is  it  that  prolapse  or  incarceration  of  iris  in  a 
sclero-corneal  wound  maybe  relied  upon  confidently  to  relieve  primary 
glaucoma  ? 


After^CompIications  303 

cocain  should  be  of  service.  I  only  remember  once 
causing  a  small  escape  of  vitreous  in  removing  a  prolapse, 
and  that  was  with  the  help  of  cocain  alone,  without 
adrenalin.  Before  the  instillation  is  begun  irrigation  of 
the  conjunctival  sac  with  perchloride  is  indicated.  (We 
used  I  in  3,000,  drop  by  drop,  for  one  minute  as  a  rule.) 
The  lids  are  firmly  separated  by  the  assistant's  fingers,  or, 
if  this  prove  insufficient,  Desmarres'  retractor  is  used  for  the 
upper  lid,  with  finger  depression  of  the  lower  lid.  Straight 
toothed  iris  forceps  are  used  for  seizing  the  iris  ;  or,  if 
curved  forceps  be  used,  their  points  must  be  directed 
upwards,  so  that  they  cannot  possibly  enter  the  wound  in 
case  the  eye  rolls  up.  The  eyeball  is  very  likely  to  turn 
upwards  when  the  iris  is  pulled  upon.  The  tissue  must 
of  course  be  released  at  once,  and,  if  the  lids  be  firmly 
held,  no  harm  ensues.  If  the  iris  is  covered  by  con- 
junctival flap,  the  latter  must  first  be  peeled  off,  a  separate 
pair  of  forceps  being  used  for  this  purpose. 

This  peeling  of  the  conjunctival  covering  may  be  accom- 
plished much  later  after  the  cataract  operation  than  one  would 
expect.  I  did  it  once  as  late  as  seventeen  days  after  the 
cataract  extraction  for  removal  of  a  small  late  prolapse,  which 
had  appeared  gradually.  In  this  case  some  bleeding  occurred 
into  the  anterior  chamber,  and  the  chamber  did  not  become 
re-established  for  some  days  afterwards.  Conjunctiva  can 
ordinarily  be  separated  from  underlying  iris  as  late  as  four  or 
five  days  at  least  after  the  formation  of  the  prolapse. 

In  dealing  with  a  small  or  moderate  protrusion  the 
iris  is  pulled  out  through  the  opening  sufficiently  to 
remove  the  whole  of  the  tissue  which  has  been  nipped  in 
the  canal.  It  is  snipped  off  with  de  Wecker's  or  other 
scissors  pressed  down  upon  the  wound  margins.  If  the 
removal  be  done  early,  within  twenty-four  hours  of  the 
occurrence   of  the    hernia,  the    pillars  of  the  coloboma 


304  Cataract  Extraction 

made  should  retract  well  away  from  the  wound,  leaving 
no  adhesion.  But  if  the  treatment  be  delayed  for  another 
day  or  more,  infiltration  will  have  spread  into  the  neigh- 
bouring iris,  and  permanent  adhesion  between  iris  and 
cornea  will  form  near  the  wound.  One  cannot  expect  to 
remove  the  whole  of  a  very  extensive  prolapse,  but  the 
greater  portion  of  it  can  be  cut  away  in  one  snip  without 
pulling  upon  the  iris  at  all  to  attempt  to  free  it  laterally. 
Though  incarceration  of  iris  is  left  at  either  end,  the 
result  in  my  experience  is  a  flat  cicatrix.  A  certain 
amount  of  retraction  appears  to  take  place,  even  though 
atropin  be  instilled  for  slight  iritis. 

After  the  small  operation  sterilized  eserin  drops  may  be 
instilled  if  the  pupil  and  iris  are  quite  clear  ;  otherwise 
atropin  may  be  required  for  threatening  iritis,  and  should 
be  used  freely  and  unhesitatingly. 

It  cannot  be  said  that  the  result  of  the  treatment  is 
always  satisfactory.  Infection*  may  have  already  entered 
the  eye,  or  may  gain  admission  at  the  time  of  the  excision. 
Adhesion  of  iris  to  the  scar  may  lead  to  secondary 
glaucoma,  or  the  weak  scar  left  after  partial  excision  of  a 
large  prolapse  may  entail  a  permanent  though  small  risk 
of  late  infection.  At  best,  after  protracted  healing,  causing 
anxiety  to  the  patient,  a  broad  and  disfiguring  coloboma 
may  be  the  result,  causing  dazzling  and  defective  orienta- 
tion. Kuhnt  recommends  the  covering  of  the  site  of  the 
prolapse  by  a  bridge  of  conjunctiva. 

Rarely  treatment  may  have  to  be  deferred  for  some  reason. 

P'or  instance,  in  one  of  our  cases  acute  dermatitis  with 
serous  exudation  from  perchloride  irritation  rendered  early 
excision  of  a  subconjunctival  prolapse  inadvisable.  And  the 
dermatitis  persisted  until  it  was  too  late  to  separate  the  con- 
junctival flap. 

*  In  one  of  our  cases  both  eyes  were  lost  later  by  sympathetic 
ophthalmia. 


After^Complications  305 

And  one  may  feel  reluctant  to  undertake  so  troublesome 
a  treatment  for  a  minute  subconjunctival  incarceration  or 
prolapse,  especially  if  the  complication  arises  late  and 
gradually ;  and  after  loss  of  vitreous  it  appears  altogether 
too  risky.  One  hesitates  even  to  perform  the  small  opera- 
tion where  the  lens  has  been  extracted  in  its  capsule 
without  loss  of  vitreous ;  also,  perhaps,  where  vitreous 
tension  has  been  very  evident  during  ordinary  extraction. 
It  is,  perhaps,  hardly  necessary  to  mention  that  any 
operative  treatment  of  a  prolapse  should  precede  that  of 
after-cataract,  in  case  the  latter  should  also  be  required. 
Should  the  order  of  procedure  be  reversed,  loss  of  vitreous 
would  be  very  probable  when  the  prolapse  was  excised. 

The  main  object  of  later  treatment  is  the  reduction  of 
the  liability  to  late  infection.  In  some  cases  also  dis- 
figurement is  removed  and  corneal  astigmatism  lessened. 
Of  small  low  protrusions  only  those  uncovered  by  con- 
junctiva would  be  interfered  with.  I  have  several  times 
cut  away  as  much  as  possible,  and  covered  the  site  by  a 
band  of  the  neighbouring  conjunctiva,  undermined  and 
drawn  down  by  a  suture  on  one  or  both  sides  of  the 
cornea.  The  accurate  fixation  of  the  conjunctival  strip 
requires  care.  In  the  case  of  a  prominent  staphyloma  it 
would  appear  perhaps  wise  to  wait  for  a  few  months  for 
partial  closure  of  the  neck  communicating  with  the 
anterior  chamber,  and  then  to  adopt  Berry's  treatment.* 
After  freely  laying  open  the  *  cyst,'  he  cauterizes  super- 
ficially the  defective  portion  of  sclero-corneal  cicatrix  in 
the  expectation  that  the  deep  inflammatory  reaction  ex- 
cited will  consolidate  the  filtering  tissue  and  lead  to  firm 
closure.  The  wall  of  the  staphyloma  is  left  as  a  covering 
to  the  cauterized  tissue. 

Simple  cauterization  has  been  recommended  and  carried 

*  Trans.  O.  S.,  xxii  (1902),  273. 

20 


3o6  Cataract  Extraction 

out  to  produce  flattening  and  condensation  of  the  tissue  of 
small  elevations  resulting  from  limited  prolapse  ;  but  I 
believe  it  is  wrong  in  principle.  It  does  not  disconnect 
the  iris  from  the  surface,  and  even  exposes  it  afresh  by 
destroying  the  epithelial  covering.  I  have  seen  two  late 
infections  in  my  own  practice  following  upon  this  treat- 
ment of  prolapse. 

Where  an  extensive  prolapse  has  been  allowed  to  heal 
in  the  wound,  partial  excision  of  the  altered  iris  tissue 
may  be  combined  with  the  application  of  a  corneo-scleral 
suture  to  produce  flattening  and  approximation  of  the 
wound  margins,  or  with  an  attempt  to  cover  the  tissue  with 
conjunctiva.  In  a  few  such  cases,  fearing  the  connexion 
of  the  uveal  tract  with  the  weak  scar,  I  have  afterwards 
separated  the  adherent  base  of  iris  at  either  side,  by  an 
irido-sclerotomy  upwards. 

Prolapse  and  Loss  of  Vitreous. 

An  extensive  prolapse  or  incarceration  of  vitreous  may  be 
found  at  the  first  dressing,  with  or  without  similar  involve- 
ment of  the  iris.  Vitreous  may  have  presented  in  the  wound 
at  the  time  of  operation,  or,  on  the  other  hand,  everything  may 
have  gone  smoothly  then.  Major  Elliot  (Madras)  has  sent  me 
notes  of  several  cases  in  which  later  prolapse  occurred,  includ- 
ing a  wide  prolapse  found  on  the  ninth  day,  a  small  one  on  the 
sixth  day,  and  another  bulging  wound  on  the  sixth  day.  Also 
of  vitreous  loss  on  the  thirteenth  day,  due  to  anteflexion  of  the 
corneal  flap  by  the  upper  lid  in  a  case  of  delayed  union  of  the 
wound.  Most  of  the  causes  of  prolapse  of  iris  may  also  lead 
to  hernia  of  the  vitreous.  On  at  least  one  occasion  on  the  day 
following  operation  I  have  seen  the  distorted  pupil  character- 
istic of  considerable  vitreous  loss,  though  no  loss  had  occurred 
at  the  time  of  operation.  Twice  I  have  seen  recurrence  of 
vitreous  escape — -in  one  case  at  the  first  dressing  twenty-four 
hours  later,  in  the  other  case  at  the  second  dressing — from 
eyes  which  had  lost  much  vitreous  during  operation.  Both 
of  these  eyes  became  atrophic  later,  though  there  was  moderate 


After^CompIications  307 

vision  in  one  at  the  time  of  discharge  from  hospital  in  spite  of 
a  retinal  detachment. 

Impaction  of  Capsule, 

besides  causing  delayed  union,  may  produce  a  permanently 
fistulous  scar,  with  its  infective  dangers,  or  may  induce  glau- 
coma. I  have  not  had  personal  experience  of  inflammatory 
troubles  arising  obviously  from  this  source,  and  feel  that  they 
must  be  rare.  Possibly  in  some  of  our  infections  ascribed  to 
entanglement  of  iris  associated  impaction  of  capsule  may  have 
been  equally  responsible.  Treacher  Collins  has  examined 
microscopically  three  eyes  in  which  entanglement  of  capsule 
in  the  wound  had  led,  apparently,  to  irido-cyclitis,  and  in  two 
of  the  cases  to  sympathetic  inflammation  of  the  fellow  eye. 


INTRAOCULAR  HEMORRHAGE. 

Bleeding  into  the  anterior  chamber  is  to  be  expected 
occasionally  within  a  few  days  after  operation  by  sclero- 
corneal  section.  I  have  known  it  to  occur  more  than  a 
fortnight  after  operation  (in  a  case  complicated  by  slight 
iritis).  It  results  from  any  strain  upon  the  wound  suffi- 
cient to  break  down  some  of  the  new  tissue  by  which  union 
is  taking  place.  New  blood-vessels  form  very  rapidly  from 
the  episcleral  tissue.  The  strain  or  injury  may  or  may 
not  be  sufficient  to  reopen  the  wound.  Thus  occasionally 
the  anterior  chamber  may  be  found  emptied  of  aqueous  and 
containing  only  a  thin,  uneven  layer  of  blood.  Much  more 
commonly  however  the  anterior  chamber  has  either  not 
been  emptied,  or  if  it  has  been  emptied,  has  become  re- 
filled by  closure  of  the  wound. 

The  absorption  is  sometimes  very  slow.  And  organiza- 
tion of  clot,  producing  after  cataract,  is  to  be  expected 
frequently  from  this  haemorrhage,  occurring  at  a  time  when 
the  eye  is  irritable  and  when  more  or  less  exudation 
is   often   present.      In   some   cases   there   are   obviously 

20 — 2 


3o8  Cataract  Extraction 

repeated  haemorrhages,  the  hyphaema  being  increased 
at  intervals  for  some  weeks.  In  some  of  these  cases 
there  is  no  obvious  explanation  of  the  persistence  or 
repetition  of  the  trouble.  One  of  our  patients,  in 
whose  eye  blood  remained  for  two  and  a  half  months, 
had  diabetes  and  albuminuria.  In  another  persistent  case 
there  was  a  troublesome  chronic  cough.  The  instillation 
of  atropin  is  indicated  to  prevent  synechiae  from  forming, 
especially  in  cases  due  to  external  violence.  In  chronic 
cases  dionin  may  help  to  promote  absorption. 

Much  more  rarely  bleeding  may  take  place  behind  the 
iris  also,  coming  obviously  from  other  sources,  in  part  at 
least.  There  are  cases  intermediate  in  gravity  between 
those  just  mentioned  and  expulsive  retrochoroidal 
haemorrhage. 

Once,  when  I  perhaps  hurt  the  eye  a  little  in  dressing  it 
three  days  after  operation,  the  patient,  an  exceedingly  nervous 
man,  suddenly  jerked  his  head  away,  and  closed  his  lids  so 
violently,  that  blood  not  only  filled  the  anterior  chamber,  but  also 
poured  from  the  reopened  wound,  and  became  diffused  through 
the  vitreous.  The  fundus  could  not  be  seen  even  a  few  months 
later.  Detachment  of  the  choroid  was  diagnosed  from  a  large 
lateral  defect  in  the  field  of  projection  of  light.  Vision  was 
practically  destroyed ;  fingers  could  not  be  counted. 

DELAYED    UNION  AND    REOPENING   OF   THE 

WOUND. 

Gaping  of  a  sclero-corneal  wound  under  a  conjunctival 
flap  has  been  sufficiently  dealt  with.  It  is  not  commonly 
referred  to  under  the  term  'delayed  union.'  But  this 
designation  is  earned  at  least  in  the  cases  where  the 
tension  of  the  eye  remains  very  low  for  weeks  after  the 
operation.  Where  this  low  tension  is  associated  with 
obvious    separation   of   the   deep   wound   one   does   not 


After^CompIications  309 

hesitate  to  ascribe  it  to  drainage  of  aqueous  through  the 
wound,  though  there  be  no  longer  any  noticeable  general 
filtration  oedema.  The  anterior  chamber  is  frequently 
rather  shallow,  but  not  always  so.  In  other  cases  gaping 
of  the  wound  is  very  slight,  and  in  still  others  it  cannot 
be  made  out  at  all.  These  soft  eyes  without  visible  separa- 
tion of  the  wound  margins,  and  with  partly  or  completely 
re-formed  anterior  chamber,  were,  I  think,  with  us  much 
commoner  since  we  operated  with  an  extensive  con- 
junctival flap  than  when  we  placed  the  incision  at  the 
superficial  sclero-corneal  junction.  And  there  does  not 
appear  to  be  sufficient  reason  to  consider  them  separately 
from  cases  in  which  the  deep  wound  gapes  visibly,  though 
there  is  always  the  possibility  that  the  leakage  may  be 
between  choroid  and  sclerotic,  and  not  through  the 
wound.  And  other  explanations  of  the  low  tension  have 
been  suggested.  For  example,  Czermak*  suggested  their 
relationship  with  so  -  called  ophthalmo  -  malacia,  and 
Chevalleraut  explains  a  case  of  enophthalmos  after  opera- 
tion as  possibly  due  to  a  sympathetic  lesion.  I  looked  for 
choroidal  detachment  in  several  cases  without  finding  it, 
but  with  after-cataract  present  the  signs  of  this  detach- 
ment may  have  escaped  notice.  I  remember  one  such 
case  several  years  ago,  discharged  from  hospital  with  the 
eye  soft  after  operation  without  conjunctival  flap ;  the 
patient  returned  a  few  months  later  with  a  prolapse  of  iris 
occupying  a  portion  of  the  cicatrix.  There  is  a  general 
feeling  that  an  anterior  chamber  of  normal  depth,  or 
deeper  than  normal  owing  to  the  removal  of  the  lens, 
shows  an  absence  of  drainage  through  the  wound  sufficient 
to  account  for  a  tension  -  2  or  -  3.  But  that  this  is  not  so 
I  have  seen  in  glaucomatous  eyes  after  the  establishment  of 

*  '  Die  Augenarztlichen  Operationen,'  p.  944. 
t  La  Clin.  Opht,  1899,  p.  23. 


3IO  Cataract  Extraction 

wide  subconjunctival  fistulae.  It  is  uncertain  how  long 
the  low  tension  may  last.  We  kept  one  patient  under 
observation  for  nearly  a  month  after  a  Czermak's  opera- 
tion, and  the  eye  was  still  very  soft. 

In  the  more  generally  recognized  leakages  through  the 
wound  the  iris  and  lens  capsule  are  in  contact  with  the 
cornea.  With  us  it  has  been  much  less  frequent,  and  the 
chamber  has  remained  empty  for  shorter  periods,  since  we 
used  a  conjunctival  flap.  With  purely  corneal  incisions 
the  chamber  more  commonly  remains  empty  from  the 
beginning,  so  far  as  one  can  judge  from  single  daily 
inspections.  With  a  conjunctival  flap  it  is  recognized 
that  early  filling  of  the  chamber  is  to  be  expected  more 
regularly,  but  re-emptying  of  the  chamber  is,  perhaps, 
rather  more  frequent  a  few  days  after  operation.  There 
may  be  haemorrhage  under  the  conjunctiva  along  the  line 
of  the  wound,  and  in  the  anterior  chamber.  And  blood 
in  these  situations  is  presumptive  evidence  of  breaking 
down  of  early  union,  though  the  anterior  chamber  may 
have  become  re-established. 

In  corneal  incisions  a  minute  opening  can  sometimes  be 
distinguished,  a  '  capillary  fistula '  through  which  the  fluid 
escapes,  due  to  entanglement  of  a  shred  of  capsule,  lens 
substance,  vitreous,  or  iris  in  the  wound.  Sometimes  a 
leaking  wound  is  a  consequence  of  a  large  incarceration  or 
prolapse  of  iris  or  vitreous,  or  of  separation  of  the  wound 
margins  by  vitreous  tension.  Other  cases  in  which  the 
lips  of  the  wound  remain  singularly  free  from  signs  of 
reaction  and  repair  have  been  ascribed  by  Mellinger  *  to 
the  too  free  use  of  cocain  during  operation. 

Among  other  suggested  explanations  may  be  mentioned 
an  uneven  incision,  too  frequent  disturbance  by  dressings, 
entropion,  and  defective  reparative  power  peculiar  to  the 

*  Beit.  z.  Augenheilkunde,  Basel,  1893. 


After^CompIications  3 1 1 

patient.  This  latter  is  suggested  by  the  occurrence  of  the 
compHcation  in  both  eyes,  or  in  two  operations  on  the  one 
eye  (e.g.,  in  a  preliminary  iridectomy  and  in  the  subse- 
quent extraction  operation).* 

The  leakage  commonly  ceases  within  a  week  or  two,  but 
considerably  longer  delays  have  been  recorded.  A.  Terson 
reported  one  lasting  a  month  and  a  half.  And  the  forma- 
tion of  a  broad  anterior  synechia  may  prevent  re-formation 
of  the  chamber  after  the  drainage  of  fluid  has  stopped  and 
the  tension  of  the  eye  risen. 

It  is  curious  that  the  complication  seldom  leads  to  evil 
consequences.  Invasion  of  corneal  wounds  by  pyogenic 
organisms  is  probably  prevented  by  the  surfaces  becoming 
covered  with  epithelium,  and  by  the  flow  of  fluid  from 
within  the  globe.  But  infections  have  been  recorded.! 
Prolapse  of  iris  may  occur,  in  eyes  other  than  those  with 
sclero-corneal  incision  gaping  under  the  conjunctiva.  Also 
anterior  synechia,  with  consequent  glaucoma  and  possibly 
extensive  corneal  opacity  (contact  keratitis).  And  one  fears 
lest  downgrowth  of  corneal  epithelium  into  the  anterior 
chamber  should  give  rise  to  glaucoma  by  blocking  the 
filtration  angle.  Elliot  *  (Madras)  relates  a  case  in  which 
the  patient  turned  down  the  corneal  flap  with  his  lid  on  the 
thirteenth  day,  causing  a  free  vitreous  escape.  A  median 
suture  was  applied  several  days  later  to  the  bulging  wound. 

In  the  large  majority  of  cases  nothing  is  required  in  the 
way  of  treatment  beyond  continued  bandaging  of  the  eye 
without  pressure,  till  the  anterior  chamber  refills.  The 
merely  soft  eyes,  with  the  chamber  normal  or  nearly  so, 
appear   to   require   simple   protection    from   injury   by  a 

*  Harlan,  Ann.  of  Ophth.,  vii  (1898),  568. 

t  See,  for  example,  Czermak,  '  Die  Augenarztlichen  Operationen,' 
S.  940  ;  Barck,  Amer.  J.  of  Oph.,  1897,  p.  281  ;  Maynard,  *  Manual 
of  Ophthalmic  Operations,'  p.  112. 

I  Personal  communication. 


312  Cataract  Extraction 

shield,  more  particularly  at  night.  Light  stimulation 
of  the  wound  surfaces  with  silver  nitrate  or  iodine  solution 
has  proved  effective  for  obstinately  leaking  corneal  wounds. 
Also  cauterization,  and  freshening  of  the  surfaces  by  the 
introduction  of  a  spatula.  These  measures  may  serve  to 
destroy  or  remove  shreds  of  tissue  incarcerated  in  the 
wound.  Massage  of  the  cornea  has  been  tried.  Iridectomy 
has  been  successfully  employed,  and  not  only  in  cases 
when  the  iris  was  involved  in  the  wound.  Possibly  it  acts 
by  freshening  the  wound  surfaces.  Entropion  may  require 
operation  or  the  removal  of  the  bandage.  Sometimes 
when  the  chamber  is  re-established  after  being  long  absent, 
the  wound  margins  may  not  be  found  in  good  apposition. 
And  the  continuance  of  (pressure)  bandaging  may  be 
required  on  this  account. 

Transient  Detachment  of  the  Choroid 

after  cataract  extraction,  first  noticed  by  Knapp  in  1868,  has 
been  studied  especially  by  Fuchs.*  It  is  rather  a  pathological 
curiosity  than  of  clinical  importance,  since  the  sight  is  only  very 
temporarily  affected.  It  is  associated  with  low  tension  of  the 
eye  and  a  shallow  or  empty  anterior  chamber,  which  may  have 
persisted  since  the  operation,  or  may  have  reappeared.  These 
clinical  signs  may  precede  recognizable  separation  of  the 
choroid  by  an  interval  of  a  day.  The  detachment  dates  com- 
monly from  the  second  to  the  eighth  day  after  operation,  but 
it  may  come  on  some  weeks,  or  even  months,  later.  It  may  be 
so  prominent  as  to  be  seen  by  focal  illumination.  On  the 
other  hand,  it  may  not  be  discernible  even  on  ophthalmoscopic 
examination,  owing  to  the  presence  of  blood  or  cortex  in  the 
pupil.  And  a  shallow  separation  readily  escapes  detection, 
since  the  separated  portion  is  of  the  same  red  colour  as  the 
rest  of  the  fundus.  It  is  recognized  by  the  dark  curved  line 
marking  its  posterior  boundary,  with  bending  and  parallactic 
movement  of  the  retinal  vessels.  In  these  low  detachments, 
especially  soon  after  their  onset,  there  may  be  folds  concentric 

*  A.f.  a,  li  (1901),  2,  199. 


After^CompIications  3 1 3 

with  the  curved  posterior  margin.  As  a  general  rule,  the 
elevation,  if  low  when  first  seen,  remains  low.  Sometimes 
both  the  development  and  the  subsidence  of  a  large  detachment 
are  very  rapid.  The  disappearance  generally  coincides  with 
refilling  of  the  anterior  chamber  and  rise  of  the  tension  to 
normal.  The  duration  of  the  detachment  is  commonly  only  a 
very  few  days,  but  it  may  be  a  month. 

The  site  of  the  separation  is  mainly  at  one  or  both  sides  of 
the  eye.  Both  sides  are,  apparently,  not  often  equally  affected. 
Detachments  above  and  below  only  occur  associated  with 
more  prominent  lateral  ones.  They  are  much  less  frequent 
than  the  latter,  and  are  always  shallow.  Separation  does  not 
take  place  readily  further  back  than  the  points  of  exit  of  the 
venffi  vorticosae. 

Fuchs  attributed  the  complication  to  the  passage  of  aqueous 
into  the  supra-choroidal  space  through  minute  rents  in  the 
soft  tissues  at  the  angle  of  the  anterior  chamber.  The  fluid  in 
the  space  has  also  been  regarded  as  a  purely  passive  serous 
accumulation,*  depending  upon  low  tension  in  the  eye,  the 
latter  being  brought  about  by  drainage  through  an  imperfectly 
united  or  reopened  wound. 

Other  more  lasting,  and  possibly  permanent,  choroidal 
detachments  occur  rarely  from  haemorrhage  during  or  after 
extraction.  See,  for  example,  the  case  mentioned  on  p.  308. 
Possibly  limited  supra-choroidal  haemorrhages  pass  unnoticed. 

Mental  Disturbance. 

Cataract  operations  are  occasionally  followed  by  various 
forms  and  degrees  of  mania,  with  hallucinations,  or  by 
simple  confusion  of  mind,  or  by  noisy  and  violent  delirium, 
in  which  the  patient  is  restrained  with  difficulty  from  pulling 
off  his  dressings.  The  mental  equilibrium  of  some  old 
people  is  upset  by  having  both  eyes  bandaged,  or  by  con- 
finement in  a  very  dark  room.  In  alcoholic  subjects  delirium 
tremens  is  a  possibility.  But  in  some  cases  no  explana- 
tion has  been  available  beyond  the  mere  influence  of  the 
operation.     Fromaget  f  suggests  auto-intoxication  as  a  cause. 

*  Thomson  Henderson,  Ophth.  Review^  xxvi  (1907),  191. 
t  Ann.  d'OcuL,  cxxiii  (1900),  183. 


314  Cataract  Extraction 

In  two  cases  he  connected  delirium  with  reduced  secretion  of 
urine  and  constipation.  Finlay  *  reported  a  similar  observation 
connecting  the  delirium  with  renal  insufficiency.  It  may  come 
on  early  or  late,  most  often  after  a  few  days.  Most  cases 
yield  to  treatment,  such  as  the  admission  of  light  and  the 
administration  of  sedatives.  But  a  few  patients  have  become 
permanently  insane,  and  deaths  have  occurred.  Care  must  be 
taken  to  prevent  injury  to  the  eye  so  far  as  possible. 

The  only  troubles  of  this  sort  with  which  we  had  experience 
in  Bombay  were  cases  of  atropin  poisoning  years  ago,  when 
ordinary  precautions  were  not  taken  by  the  attendants  in 
instilling  the  drops. 

Flatulent  Distension 

of  the  abdomen  is  very  commonly  found  in  India,  especially 
in  private  patients,  the  day  after  the  operation.  The  patient 
has  generally  passed  a  sleepless  night,  and  often  has  pains  in 
his  loins.  These  troubles  are  due  to  the  patient  having  lain 
on  his  back,  afraid  of  the  smallest  movement,  thinking  that 
his  eyes  might  be  injured  thereby. 


SECONDARY  GLAUCOMA. 

Glaucoma  follows  the  operations  of  cataract  extraction 
and  of  needling  for  after-cataract  in  a  small  percentage  t 
of  cases.  It  may  set  in  at  any  period.  A  sudden  rise  of 
tension  may  develop  within  twenty-four  hours  after  dis- 
cission, t  A  slower  elevation  of  tension  may  mark  the 
consolidation  of  the  cicatrix  a  few  weeks  after  extraction 
of  the  lens,  or  may  be  found  as  the  cause  of  a  gradual 
deterioration  of  vision  years  later. 

It  is  impossible  to  deny  that  some  of  the  glaucoma  seen 
after  these  operations   may  be   primary,  the  association 

*  Arch,  of  Ophth.,  xxxiii  (1904),  5. 

t  Marshall  gives  a  percentage  of  2-08  in  secondary  operations  at 
Moorfields. 

:J:  Very  rarely  at  such  an  early  period  after  cataract  extraction,  and 
then  only  by  exclusion  of  the  pupil. 


After^CompIications  3 1 5 

between  the  condition  and  the  operation  being  fortuitous. 
But  in  many  cases  the  causal  relationship  is  unmistakable. 

Glaucoma  may  have  been  present  in  the  eye  before  opera- 
tion. Or  the  primary  nature  of  subsequent  glaucoma  may  be 
suggested  by  the  same  condition  occurring  in  the  fellow  eye, 
if,  moreover,  the  operation  and  healing  of  the  wound  has 
been  uneventful  ;  more  especially  if  there  is  neither  incarcera- 
tion of  iris  or  capsule  in  the  scar,  nor  adhesion  to  the  scar,  and 
if  the  interval  between  operation  and  the  recognition  of  tension 
is  long. 

The  secondary  nature  of  the  affection  may  be  attested 
clinically  by  anatomical  conditions  known  to  be  effective,  or 
may  be  suggested  by  almost  immediate  onset  after  operation. 
And  the  greater  frequency  of  the  complication  after  com- 
bined extraction  than  after  simple  extraction  is  evidence  of  an 
etiological  relationship. 

Where  the  complication  supervenes  upon  cataract  extrac- 
tion supplemented  by  quite  early  discission,  there  may 
naturally  be  some  doubt  as  to  the  relative  parts  played  by 
each  operation  as  causative  factors.  So  far  as  the  evidence 
goes,  discission  cannot  be  considered  accountable  for  any 
glaucoma  which  is  not  of  early  onset,  unless  it  be  through  the 
instrumentality  of  an  iritis  or  irido-cyclitis. 

It  is,  of  course,  possible  that  a  predisposition  to  primary 
glaucoma  may  combine  with  some  result  of  operation  in  the 
development  of  the  complication.  But  the  conditions  clinically 
recognizable  as  predisposing  to  primary  glaucoma — shallow 
anterior  chamber,  small  cornea,  hypermetropia — can  have 
little  influence  in  this  relationship.  Indeed,  one  may  suppose 
that  the  deepening  of  the  chamber  from  a  satisfactory  lens 
extraction  may  at  times  serve  as  an  efficient  prophylactic 
against  the  onset  of  glaucoma. 

Much  of  the  high  tension  met  with  after  either  the 
major  or  the  minor  operation  is  inflammatory  in  origin. 
Various  forms  and  degrees  of  iritis  and  irido-cyclitis  may 
act  here  as  they  do  quite  apart  from  operation,  either 
through  annular  posterior  synechia  excluding  the  pupil, 
or  more  commonly  by  the  accumulation  of  albuminous 


3 


1 6  Cataract  Extraction 


fluid    and   exudate   and   the    blockage   of    the   filtration 
channels. 

Interest,  however,  centres  more  in  the  development  of 
high  tension  quite  apart  from  inflammatory  changes  or 
insufficiently  accounted  for  by  them.  After  cataract 
extraction  incarceration  of  iris  or  capsule,  or  both,  in  the 
wound  has  been  most  frequently  blamed.  Besides  the 
obliteration  of  the  filtration  angle  at  the  actual  site  of  the 
impaction,  broad  or  narrow,  there  may  be  extensive 
adhesion  between  base  of  iris  and  cornea  in  the  imme- 
diate neighbourhood.  This  is  owing  to  localized  changes 
of  inflammatory  nature,  excited  around  the  impacted  tissue, 
and  spreading  more  or  less  to  the  neighbouring  iris.  The 
forward  displacement  of  the  iris  to  the  line  of  the  scar, 
especially  where  the  wound  has  been  purely  corneal,  may 
be  sufficient  to  narrow  the  whole  circle  of  the  filtration 
angle. 

In  cases  of  chronic  iritis  it  may  be  impossible  to 
apportion  the  influences  of  inflammation  and  adhesion  to 
the  line  of  the  scar.  As  the  inflammation  persists,  and  as 
fibrous  tissue  replaces  the  proper  iris  tissue,  the  drawing 
forward  of  the  iris  becomes  more  marked. 

Glaucoma  is  more  common  after  combined  extraction 
because  of  entanglements  of  the  tissues  in  the  wound,  and 
also  of  mere  adhesions  to  the  cicatrix.  Here  the  extent 
of  the  adhesions  and  the  position  of  the  wound-line 
(purely  corneal  or  sclero-corneal)  are  important  con- 
siderations, for  it  is  comparatively  rarely  that  forward 
displacement  of  the  root  of  one  or  both  pillars  of  the 
coloboma  may  not  be  found  on  focal  illumination  after 
the  combined  operation.  In  a  glaucomatous  eye 
whence  the  lens  had  been  removed  in  its  capsule 
Treacher  Collins  once  found  adhesion  of  hyaloid  mem- 
brane to  the  scar  accountable  for  closure  of  the  filtration 


After^CompIications  3 1 7 

angle.  This  may  possibly  result  from  any  vitreous 
prolapse. 

Inclusion  of  a  tag  of  iris  or  capsule  in  the  wound  may 
also  be  responsible  for  (i)  delayed  refilling  of  the  anterior 
chamber,  and  possibly  (2)  downgrowth  of  surface  epi- 
thelium into  the  anterior  chamber.  Later  there  may  be 
(3)  "a  continual  drag  upon  the  ciliary  processes,  exag- 
gerated by  the  perpetual  movements  of  the  iris  and  ciliary 
muscle.  In  this  manner  ciliary  irritation  is  set  up."*  The 
empty  chamber  must  obviously  aid  in  the  formation  of 
peripheral  anterior  synechise.t  The  downgrowth  of  corneal 
or  conjunctival  epithelium  may  be  so  rapid  as  to  cover  the 
whole  depth  of  the  wound  surfaces  in  four  days.  It  may 
extend  to  line  the  anterior,  and  even  the  posterior,^ 
chamber  completely,  perhaps  closing  the  pupil  and  colo- 
boma,  or  it  may  be  confined  to  the  neighbourhood  of  the 
wound,  obstructing  the  filtration  angle.  The  layer  covering 
the  iris,  or  actual  cyst-formation,  may  or  may  not  be  visible 
clinically. 

It  has  been  suggested  that  cortical  remains  may  cause 
glaucoma  (i)  by  irritating  the  iris  and  ciliary  body,  and  so 
causing  increased  secretion ;  (2)  by  blocking  the  spaces 
leading  to  the  canal  of  Schlemm ;  and  (3)  by  swelling 
sufficiently  to  press  forward  the  root  of  the  iris.  Intra- 
ocular haemorrhage  occurring  after  the  wound  has  united 
has  been  mentioned  also  as  a  possible  source  of  tension. 

A  sudden  rise  of  tension  after  discission  (said  to  be 
more  common  in  cases  where  the  extraction  was  without 

*  Parsons,  'The  Pathology  of  the  Eye,'  iii,  1083. 

t  Our  three  Bombay  cases  of  secondary  glaucoma  mentioned  on 
p.  247,  due  to  accidental  irrigation  of  the  anterior  chamber  with  per- 
chloride  lotion,  were  probably  brought  about  by  peripheral  anterior 
synechia.  This  would  be  permitted  by  destruction  of  the  endothelial 
lining  of  the  anterior  chamber. 

X  Elschnig,  A"/.  Md/./.  A.,  xli  (1903). 


3i8  Cataract  Extraction 

iridectomy)  has  been  explained  as  the  result  of  additional 
obstruction  of  filtration  paths  already  restricted  by  sequelae 
of  the  extraction  operation.  Reactionary  swelling  of  the 
ciliary  processes  pushing  the  base  of  the  iris  forward  may 
temporarily  close  an  already  narrow  filtration  angle,  or 
some  imprisoned  cortical  matter  may  be  set  free  into  the 
chamber,  choking  up  the  meshes  of  the  pectinate  ligament. 
Some  cases  in  eyes  with  no  obvious  peripheral  shallowing 
of  the  chamber  appear  to  be  explicable  only  by  the  advance 
of  broken-up  (perhaps  abnormally  fluid)  vitreous  to  mingle 
with  the  aqueous. 

In  one  such  case  of  tension  following  the  double-needle 
operation  in  a  child  in  my  practice,  the  presence  of  vitreous  in 
the  anterior  chamber  was  shown  by  failure  to  empty  the 
chamber  on  tapping  with  a  narrow  knife. 

Bajardi's*  production  of  plus  tension  in  aphakic  eyes  of 
rabbits  by  injecting  vitreous  into  the  anterior  chamber  is 
interesting. 

Knappt  and  Dalen;]:  depict  the  persistent  forms  of  glaucoma 
following  discission  as  more  or  less  inflammatory,  with  forward 
protrusion  of  iris,  and  presumably  seclusion  of  the  pupil.  But 
many  of  these  cases  with  bulging  iris  are  certainly  not  entirely 
or  mainly  due  to  general  iritis  or  irido-cyclitis.  For  there  may 
be  little  or  no  exudation  visible  binding  down  the  pupillary 
margin  to  the  capsule,  and  the  signs  of  seclusion  may  set  in 
within  twenty-four  hours — far  too  rapidly  for  the  formation  of 
annular  posterior  synechia  from  general  iritis.  The  sugges- 
tion that  these  appearances  may  represent  incarceration  of 
vitreous  in  the  pupil,  kept  small  by  spasm  of  the  sphincter, 
appears  a  little  strained.  A  case  of  my  own  throws  some  light 
on  their  origin.  On  the  day  following  a  simple  extraction  of 
a  Morgagnian  cataract,  containing  fluid  of  unusually  thick 
creamy  consistence,  the  eye  was  painful  and  injected,  pupil 
small,    and  anterior   chamber   not   refilled.      It  was  not   till 

*  R.  Ace.  di  Med.  di  Turino,  Luglio,  1896. 
t  A./.A.,xx\  (1895),  8. 

X  Mitteilungen   aus   der  Augeti.   Klinik   in    Stockholm.,   3    Heft, 
Jiinner,  1901,  S.  75. 


After^CompIications  3 1 9 

another  day  had  passed  that  the  tension  was  tested  and  found 
to  be  high.  The  tension  and  the  pain  were  reheved  at  once 
by  a  simple  puncture  through  the  iris.  There  was  undoubtedly 
exclusion  of  the  pupil,  brought  about  by  the  irritation  of  the 
creamy  lens  debris.  It  had  been  noted  at  the  cataract  opera- 
tion that  a  little  of  this  material  repeatedly  crept  into  the 
pupillary  area  from  behind  the  iris  even  after  free  irrigation  of 
the  anterior  chamber.  And  doubtless  some  trace  of  it 
remained  behind.  It  is  worthy  of  note  in  this  connexion  that 
after  Knapp's  simple  extractions  with  '  peripheric  splitting  '  of 
the  capsule,  the  reopening  of  the  capsular  sac  by  the  needling 
is  very  likely  at  times  to  set  free  imprisoned,  overripe,  irritat- 
ing cortical  remains.  This  form  of  glaucoma  appears  to  be 
the  only  one  which  can  arise  thus  early  after  cataract  extrac- 
tion— i.e.,  in  an  eye  with  a  large  recent  wound.  It  can 
scarcely  happen  after  combined  extraction.  (In  Norris  and 
Oliver's  '  System,'  iv.  392,  mention  is  made  of  the  fact  that 
early  onset  of  glaucoma  is  seen  more  after  simple  than  after 
combined  extraction.) 

Treacher  Collins  has  found  adhesion  of  capsule  to  the  site 
of  a  needle  puncture  as  an  additional  cause  of  glaucoma. 
Clinically,  it  is,  I  believe,  not  rare  long  after  discission  through 
a  corneal  puncture  to  see  a  fine  grey  thread  running  back  from 
the  minute  corneal  scar.  But  presumably  these  threads  are 
mostly  the  remains  of  altered  vitreous. 

Cases  of  very  slow  onset  after  cataract  extraction,  whether 
supplemented  or  not  by  discission — cases  for  which  treatment 
is  sought  months  or  years  later — are  naturally  often  those  in 
which  the  causes  above  given  are  least  obvious,  and  in  which, 
therefore,  the  presumption  of  primary  glaucoma  appears 
reasonable. 

De  Lapersonne  believes  renal  impermeability  to  be  an 
important  factor  in  the  causation  of  the  plus  tension. 

Our  notable  exemption  from  this  complication  in 
Bombay,  so  far  as  cataract  extraction  is  concerned,  has 
been  alluded  to  already.  We  considered  it  due  largely  to 
the  use  of  the  conjunctival  flap,  which  not  only  led  to  the 
formation  of  many  filtering  cicatrices,  but  also  ensured 
early   refilling   of    the   anterior   chamber   and   prevented 


320  Cataract  Extraction 

downgrowth  of  epithelium.  Important  also  has  been  the 
rarity  of  inflammatory  complications.  And  satisfactory 
replacement  of  iris  and  capsule  during  operation,  with 
retention  of  activity  in  the  pupillary  sphincter,  must  have 
had  a  definite  prophylactic  influence. 

Knapp*  says,  "  Glaucoma  is  the  only  consequence  of  dis- 
cission which  may  be  fairly  considered  as  inherent  to  the 
operative  procedure.  A  low  degree  of  increase  of  tension 
appears  not  infrequently,  perhaps,  during  the  first  twelve 
hours  as  reaction  from  the  operation,  and  disappears  without 
treatment." 

The  treatment  of  a  malady  of  such  diverse  origin  cannot 
be  uniform.  Many  of  the  early  cases,  and  particularly 
those  excited  by  needling,  subside  under  treatment  by 
eserin.  Dionin  and  both  hot  and  cold  applications  have 
also  been  used.  And  Pagenstecher  has  recommended  the 
administration  of  sodium  salicylate.  Even  cases  of  inflam- 
matory origin  have  been  treated  by  eserin.  But  it  is  more 
rational  to  treat  them  with  atropin,  relieving  the  tension 
temporarily  by  paracentesis  or  sclerotomy.  A  prolonged 
reduction  of  tension  may  be  secured  by  a  modified  subcon- 
junctival paracentesis  (see  Fig.  95).  Where  there  is  ex- 
clusion of  the  pupil,  transfixion  of  the  pupillary  membrane 
is  indicated,  possibly  succeeded  by  iridectomy  or  irido- 
tomy.  For  adhesion  or  incarceration  of  iris  or  capsule 
the  mere  division  of  these  tissues  may  be  sufficient,  or  it 
may  be  combined  with  sclerotomy  (Narben-sclerotomie, 
Ouletomie).  Or  iridectomy  may  be  preferred.  For  the 
late  chronic  forms  of  glaucoma  either  iridectomy  or  one 
of  the  newer  operative  measures  appears  to  be  indicated — 
Heine's  detachment  of  the  ciliary  body,  or  the  formation 
of  a  filtering  cicatrix  (Lagrange,  Herbert),  provided  the 

*  Norris  and  Oliver's  '  System,'  iii,  816. 


After^CompIications  321 

posterior  capsule  has  not  been  punctured,  allowing  vitreous 
to  come  forward  into  the  cicatrix.  The  prognosis  is  not 
always  favourable,  in  so  far  as  the  condition  may  possibly 
be  brought  about  through  epithelial  ingrowth,  over  which 
we  have  no  control. 


AFTER-CATARACT. 

After-cataract  is  the  term  applied  to  the  opaque  tissues, 
mostly  membranous,  present  in  some  degree  in  the  pupil 
and  coloboma  after  the  very  large  majority  of  ordinary 
cataract  extractions.  It  is  used  also  for  any  folding  of 
transparent  capsule  by  which  visual  acuteness  is  lowered, 
and  for  occlusion  of  pupil  and  coloboma,  the  result  of 
iritis  or  irido-cyclitis  after  the  operation.  Early  after- 
cataract  may  be  largely  or  entirely  of  temporary  nature, 
consisting  of  lens  matter,  blood-clot  or  lymph.  On  the 
other  hand,  progressive  capsular  degeneration  may  cause  a 
slow  reduction  of  vision  in  the  course  of  years. 

Vision  may  be  lowered  by  the  following  conditions, 
singly  or  combined : 

I.  Capsular  abnormalities. 

(a)  Thickenings,  proliferations  of  lens  cells,  dating  from 
before  operation.  A  large,  dense  anterior  plaque  of  an 
overripe,  shrunken  cataract  may  have  been  left  behind  for 
some  reason.  Or  there  may  be  a  much  thinner  posterior 
central  patch  or  ring  of  capsular  opacity.  More  common 
is  the  opaque  capsule  of  a  Morgagnian  cataract — either 
simple  diffuse  cloudiness  aifecting  chiefly  or  entirely  the 
anterior  capsule,  or  the  same  with  dense  white  points 
added.  The  edges  of  the  opening  already  made  in  such 
an  inelastic  capsule  may  lie  almost  in  apposition,  in  which 
case  the  visual  defect  may  be  attributable  more  to  the 
want   of  elasticity  than  to    the  opacity.     Besides   these 

21 


32  2  Cataract  Extraction 

more  obvious  opacities  one  notices,  on  careful  examination 
at  the  time  of  discharge  of  the  patient  from  hospital,  that 
the  anterior  capsule  seldom  appears  altogether  transparent. 
It  is  faintly  cloudy,  and  the  margins  of  the  opening  in  it, 
more  or  less  curled  up,  are  frequently  visible  as  fine  grey 
lines.* 

To  what  extent  proliferation  of  lens  cells t  after  opera- 
tion is  accountable  for  central  opacities  found  later  is 
uncertain.     Certainly  in  some  cases  there  is  no  such  pro- 


FiG.  8i.  Fig.  82. 

Late  After-Cataract,  purely  Capsular,  as  seen  with 

Corneal  Loupe  through  the  Dilated  Pupil. 

liferation.  It  appears  more  likely  to  occur  peripherally  in 
pockets  shut  off  from  the  anterior  chamber  by  union  of 
the  two  layers  of  capsule. 

(b)  As  early  as  six  months  after  operation,  but  much 
more  after  several  years,  changes  may  be  found  especially 
in  the  anterior  capsule  (see  Figs.  81  and  82)  which  have 
developed  since  the  cataract  extraction  and  which  are 
different  from  anything  found  shortly  after  operation,  t 
The  membrane  may  appear  almost  or  quite  clear  on 
examination  by  focal  illumination,  but  direct  ophthalmo- 

*  At  this  early  period  it  may  be  difficult  to  decide  whether  some 
faint  grey  patches  belong  to  the  posterior  capsule  or  represent  cortex 
left  behind.  It  is  also  sometimes  impossible,  even  with  the  pupil  dilated, 
to  distinguish  the  opening  in  the  anterior  capsule.  It  is  possible 
that  in  such  cases,  no  capsule  having  been  removed,  but  the  opening 
in  it  having  been  large,  the  anterior  capsule  may  have  completely  re 
tracted  behind  the  iris. 

t  See  Wagenmann,  A./.  O.,  xxxv,  173. 

X  I  think  that  once  I  found  a  mere  trace  of  these  changes  quite 
early  after  cataract  operation. 


After^Complications  323 

scopic  examination  with  a +  20  lens  reveals  fine  opaque 
(black)  lines,  sharply  defined.  They  are  mostly  disposed 
in  the  form  of  circles,  varying  in  size,  but  all  minute. 
But  there  are  also,  usually,  other  irregularly  disposed 
lines.  From  their  appearance  one  would  judge  that 
these  changes  indicate  degeneration  of  the  elastic  cap- 
sule itself  rather  than  abnormalities  of  the  cells  lining 
it.  I  have  not  seen  the  exact  condition  described  else- 
where. 

(c)  Fine  parallel  or  radiating  folds  in  the  capsule  may 
sometimes  be  seen  within  a  fortnight  after  extraction,  but 
are  more  common  later.  They  are  more  noticeable  by 
focal  illumination  than  with  the  ophthalmoscope.  They 
are  often  caused  obviously  by  the  traction  of  organizing 
deposits  of  blood  or  lymph,  and  they  are  usually  situated 
so  as  to  influence  central  vision  more  or  less.  An  un- 
common and  ill-marked  form  of  unevenness  is  a  waviness 
of  the  loose  anterior  portion  of  capsule,  after  operation  on 
a  Morgagnian  cataract. 

2.  Cortex  left  behind. 

If  one  systematically  operates  upon  rather  unripe  cataracts, 
one  must  at  times  leave  a  layer  of  lens  substance  occupying 
the  whole  area  of  pupil  and  coloboma,  scarcely  visible,  per- 
haps, at  the  time  of  operation,  but  opaque  and  swollen  after 
twenty-four  hours.  Or  trouble  from  haemorrhage  into  the 
anterior  chamber,  or  from  escape  of  vitreous,  may  interfere 
with  the  removal  of  ripe  cortex.  But  ordinarily,  only  thin 
layers  of  one  or  more  sectors  of  soft  flocculent  material 
are  left,  projecting  into  the  pupil  from  the  periphery.  For 
the  rapid  disappearance  of  lens  debris  the  free  access  of 
aqueous  humour  is  necessary.  Therefore,  slow  absorption  is 
to  be  expected  of  lens  matter  which  is  embedded  in  vitreous, 
or  which  becomes  enclosed  in  a  pocket  by  union  of  the  two 
layers  of  capsule.  This  point  is  insisted  upon  by  the  advocates 
of  the  use  of  capsule  forceps.  Cortex  which  is  exceptionally 
slow  of  absorption  is  the  cream-coloured,  firm,  equatorial  ring 

21 — 2 


324  Cataract  Extraction 

of  the  overripe  discoid  cataract ;  but  this  is  almost  never  left 
behind  except  when  there  is  vitreous  accident. 

3.  A  fortnight  or  so  after  the  cataract  operation  any 
remains  of  blood-clot  still  present  are  usually  seen  as  grey 
bands  or  patches  with  red  centres.  Both  these  and  any 
pigmented  lymph  deposits  present  may  be  found  exclu- 
sively or  mainly  along  the  edges  of  the  capsular  opening. 
Almost  invariably  present  with  them,  though  not  necessarily 
directly  continuous  with  them,  are  one  or  more  posterior 
synechias.  One  confidently  expects  by  far  the  greater  part 
of  this  early  material  to  become  absorbed,  and  one  is  often 
surprised  at  the  small  effect  which  it  has  upon  visual  acute- 
ness.  But  the  fine  bands  or  thin  membrane  which  may 
ultimately  result  from  these  deposits  are  often  somewhat 
centrally  situated,  and  they  are  apt  by  contraction  to 
produce  considerable  wrinkling  of  neighbouring  capsule. 

From  the  scantiest  deposits  and  those  consisting  almost 
entirely  of  blood-remains,  and  recognized  as  non-in- 
flammatory,* it  is  but  a  step  to  others  mainly  lymphoid, 
and  found  in  eyes  with  somewhat  prolonged  and  intense 
ciliary  injection,  but  possibly  without  the  slightest  pain  or 
other  symptom  of  iritis.  And  from  such  cases  with  very  fair 
central  vision,  only  slightly  "  complicated,"  it  is  but 
another  step  to  complete  occlusion  of  pupil  and  colo- 
boma  from  iritis,  reducing  sight  to  moving  bodies  only. 
Many  of  these  cases  advance  later  a  further  stage  to 
almost  pin-point  contraction  of  pupil  and  coloboma,  with 
drawing  up  to  the  line  of  the  wound.  Together  with 
this  an  atrophic  and  discoloured  iris  indicates  total 
posterior  synechia,  and  the  existence  of  a  fairly  thick 
layer  of  tissue  binding  together  the  capsule  and  remains 
of  iris.  And  some  opacity  of  vitreous  is  probable, 
especially  if  the  tension  is  at  all  reduced. 

*  See  Bates,  New  York  Med.  Jour. ^  July  7,  1900. 


After^CompIications  325 

Treatment. 

Where  vision  is  obscured  by  a  large  quantity  of 
cortex  in  the  pupil  there  is,  as  a  rule,  no  alternative  but 
to  wait  for  its  absorption,  hastening  this,  if  possible,  by 
various  means.  Whether  absorption  is  hastened  by  the 
administration  of  drugs  is  somewhat  doubtful.  Blue  pill 
and  other  preparations  of  mercury  have  had  a  certain 
repute,  given  for  this  purpose.  Possibly  any  benefit 
derived  from  them  in  this  respect  may  have  been  indirect, 
through  the  control  of  iritis.  The  use  of  dionin  locally 
has  been  recommended,  also  subconjunctival  salt  injec- 
tions.* 

Especially  in  eyes  where  the  deep  wound  gapes  a  little 
under  a  large  conjunctival  flap,  one  may  feel  tempted 
to  peel  back  the  conjunctiva  at  some  point  ten  days  or 
more  after  operation,  and  to  express  some  of  the  now  fulh" 
ripened  lens  matter.  I  have  elevated  the  conjunctival  flap 
sufficiently  with  forceps  to  insert  a  Graefe's  knife  through 
the  healing  wound  for  this  purpose  as  late  as  twenty-two 
days  after  the  cataract  extraction.  One  would  not  care  to 
do  this  if  there  were  still  any  considerable  injection  of  the 
eye,  or  if  there  were  any  noticeable  conjunctival  secretion. 
And  even  so,  one  would  scarcely  care  to  wash  out  the 
cortex  with  the  douche  at  this  early  period.  But  with 
proper  precautions  simple  expression  through  a  small  sub- 
conjunctival opening  appears  to  be  free  from  objection. 

Especially  in  hospital  work  and  where  one  cannot  be 
sure  of  keeping  the  patient  under  prolonged  observation, 
scanty  cortex  in  the  pupillary  area,  with  or  without  blood 
remains  and  lymph  deposit,  may  impel  one  to  early  dis- 
cission of  the  after-cataract  (see  below).  One  realizes  that 
most  of  the  opacity  is  of  a  purely  temporary  nature.     But 

*  G.  Hirsch,  A.  f.  O.,  xlii  (1900). 


326  Cataract  Extraction 

one  has  the  impression  that  mild  irritation  excited  by  the 
lens  substance  may  predispose  to  organization,  rather  than 
to  absorption,  of  fibrinous  deposit,  and  may  tend  also  to 
stimulate  the  lens  cells  lining  the  anterior  capsule  to 
proliferate. 

The  treatment  of  after-cataract  other  than  cortical  re- 
mains is  operative.  There  have  been  numerous  small 
modifications  in  technique  and  in  instruments,  but  the 
outlines  of  treatment  are  defined. 

The  large  majority  of  after-cataracts  can  be  sufficiently 
displaced  by  simple  *  needling '  or  division  w^ith  a  narrow 
knife  or  knife-needle.  Others,  more  resistant,  may  be  torn 
between  two  needles  or  cut  by  scissors.  Dense  capsular 
opacities  of  overripe  cataracts  may  have  to  be  extracted. 

The  proportion  of  after-cataracts  for  which  needling  is 
unsuitable  varies  greatly  in  the  practice  of  different 
surgeons  and  in  different  hospitals.  In  Bombay  this  pro- 
portion has  been  extremely  small.  It  depends  (i)  on  the 
amount  of  iritis  and  irido-cyclitis  complicating  the  ex- 
traction operations;  (2)  on  the  number  of  overripe 
shrunken  and  Morgagnian  cataracts  met  with,  and  removed 
without  their  capsules;  and  (3)  on  the  date  upon  which  the 
supplementary  treatment  is  generally  undertaken.  Tough 
and  inelastic  capsules,  demanding  tearing  between  two 
needles  or  division  with  scissors,  are  much  less  common 
shortly  after  the  primary  operation  than  months  or  years 
later.  And  there  are  few  capsules  already  opaque  before 
the  cataract  extraction  which  cannot  be  removed  advan- 
tageously with  the  cataract.  It  is  well  before  entering 
into  the  details  of  the  treatment  to  grasp  the  principles 
which  govern  the  application  of  the  various  measures.  It 
is  necessary  to  weigh  the  risks  run  against  the  benefits 
hoped  for.  One  must  inquire  why  in  some  hands  even  the 
simplest  of  these  supplementary  operations  gained   the 


After^CompIications  327 

repute  of  being  more  dangerous  than  the  primary  extraction 
operation.  And  one  must  note  the  precautions  which 
have  sufficed  to  remove  practically  all  risk  from  simple 
capsulotomy  at  least  (see  Kuhnt's  results,  p.  350,  and  my 
own,  p.  346).  Disaster  is  remarkable  and  disappointing  in 
so  trivial  an  operation.  The  accidents  which  led  some 
surgeons  to  give  up  the  treatment  of  after-cataract  almost 
entirely  were  mainly  infective,  and  included  both  pan- 
ophthalmitis and  destructive  irido-cyclitis.  There  has 
been  some  trouble  also  from  secondary  glaucoma,  and 
detachment  of  the  retina  has  been  known  to  follow. 

Infection. — Devereux  Marshall*  reported  in  a  list  of 
512  secondary  operations  i*02  per  cent,  suppurations  and 
5"58  per  cent,  slow  inflammatory  changes,  which  ultimately 
diminished  or  destroyed  sight.  Trousseaut  reported  among 
nineteen  discissions  one  panophthalmitis,  four  cases  of 
iritis,  one  of  cyclitis,  and  one  irido-choroiditis ;  among  ten 
extractions  of  capsule  two  cases  of  iritis  and  two  of  irido- 
choroiditis.  During  the  period  and  at  the  same  hospital 
in  which  these  secondary  operations  were  performed,  he 
extracted  453  cataracts  with  no  suppurations  and  only 
twelve  cases  of  iritis. 

It  is  recognized  that  infective  inflammations  have  been 
mainly  attributable  to  micro-organisms  which  have  gained 
entrance  through  punctures  and  incisions  kept  open  by 
vitreous  lying  in  them.  After  discission  of  a  membranous 
cataract  through  a  corneal  puncture,  under  certain  con- 
ditions the  needle  on  withdrawal  brings  with  it  a  fine 
thread  of  vitreous,  a  few  millimetres  long,  which  remains 
hanging  from  the  wound  possibly  for  some  days.  Haab,  in 
1890,  pointed  out  the  nature  and  the  danger  of  this  occur- 
rence.    And  even  where  no  hanging  thread  is  visible,  it  is 

*  R.  L.  O.  H.  Reports,  xiv  (1894),  56. 
t  Ann.  d'OcuL,  cvii  (1892),  338. 


328  Cataract  Extraction 

possible  that  vitreous,  especially  if  abnormally  fluid,  may 
find  its  way  into  the  puncture  unless  the  latter  close 
promptly  on  withdrawal  of  the  instrument.  Thus  the 
channel  for  infection  from  the  conjunctival  surface  is 
opened.  The  gradual  backward  spread  of  opacity  has 
been  seen  in  a  band  of  vitreous  thus  entangled.  That  this 
has  been  the  main  source  of  disaster  in  the  treatment  of 
after-cataract  is  certain,  for  it  is  the  combination  of  corneal 
puncture  with  vitreous  incision  that  has  proved  dangerous. 
The  mere  corneal  puncture,  as  shown  in  discission  of  the 
complete  lens,  is  harmless  in  this  respect.  And  the  same 
appears  to  be  true  of  vitreous  incision,  provided  the  humour 
is  effectively  shut  off  from  connexion  with  the  surface  of 
the  globe.  This  has  been  shown  fairly  well  in  the  posterior 
scleral  discission  of  da  Gama  Pinto  and  others,  in  equa- 
torial puncture  for  glaucoma,  and  so  on.  In  a  discission 
through  the  anterior  chamber  a  puncture  immediately 
behind  the  limbus  may  be  so  readily  furnished  with  a 
covering  by  sliding  the  movable  ocular  conjunctiva,  that  it 
seems  foolish  to  neglect  this  very  obvious  precaution.  Our 
Bombay  work  and  Kuhnt's  larger  experience  testify  very 
strongly  to  the  efficacy  of  a  conjunctival  covering  in 
preventing  infection.  We  could  afford  to  ignore  the  threads 
of  vitreous  which  were  occasionally  seen  on  withdrawal 
of  the  knife.  Even  without  sliding  the  conjunctiva  the 
insertion  of  the  knife  in  this  situation  through  vascular 
tissues  is  considered  safer  than  through  the  cornea.  And 
the  peripheral  site  is  less  easily  reached  by  vitreous  at 
the  close  of  a  needling,  than  if  the  instrument  had  been 
inserted  quite  near  the  opening  made  in  the  capsule. 

Knapp,  however,  whose  excellent  pioneer  work  did 
much  to  establish  the  treatment  of  after-cataract,  has 
worked  always  with  a  corneal  puncture  placed  at  some 
distance  from  the  limbus.    His  success  is  explained  by  the 


After-Complications  329 

avoidance  of  all  unnecessary  disturbance  of  the  vitreous  and 
by  the  use  of  a  satisfactory  instrument.  He  has  insisted 
upon  the  importance  of  cutting  instead  of  tearing  the 
membrane,  and  with  his  needle-knife  he  has  been  able  to 
do  this  without  churning  or  displacement  or  deep  penetra- 
tion of  the  vitreous.  Hence  small  chance  of  the  vitreous 
humour  coming  forward  to  the  corneal  wound.  Further, 
with  a  correctly  proportioned  needle-knife  he  has  commonly 
ensured  immediate  closure  of  the  corneal  puncture,  as 
shown  by  more  or  less  complete  retention  of  aqueous. 

It  is  obvious  that  immediate  closure  of  the  puncture  is 
essential  if  the  risk  of  incarceration  of  vitreous  is  to  be 
excluded.  And  to  this  end  the  opening  should  be  as  small 
as  possible,  and  made  without  force.  When  the  blade  of 
a  needle-knife  has  become  worn  down  a  little  by  repeated 
setting,  the  stem  following  it  has  to  force  an  entrance 
through  a  puncture  which  is  too  small  for  it.  Such  an 
opening  cannot  be  expected  to  close  quickly  afterwards. 
The  same  applies  if  the  small  wound  be  distorted  by  very 
free  movement  of  the  needle  within  it. 

To  sum  up,  it  appears  safest  to  place  the  puncture 
peripherally,  partly  in  the  sclerotic,  and  subconjunctivally. 
If  corneal,  it  must  be  as  small  as  possible,  and  must  be 
made  with  a  correctly  proportioned  sharp  instrument, 
and  must  not  be  unnecessarily  enlarged  by  free  movement 
of  the  instrument.  And,  finally,  the  vitreous  must  not  be 
disturbed  more  than  can  be  helped. 

Inflammatory  reaction  mostly  of  low  type  has  been 
attributed  also  to  pull  upon  the  ciliary  body  during  the 
division  of  a  tough  membrane.  The  awakening  of  old 
dormant  mischief  appears  to  explain  at  least  the  severer 
and  more  resistant  cases,  apparently  of  infective  origin.* 

*  One  may  suppose  that  encysted  micro-organisms  are  set  free  into 
the  tissues  by  the  stretching ;  or  more  probably  that  a  few  enfeebled 


33*^  Cataract  Extraction 

Naturally  this  cannot  apply  when  the  progress  after 
the  primary  operation  has  been  entirely  uncompli- 
cated. 

Particular  care  is  taken  nowadays  to  cut  the  membrane 
always  with  the  least  possible  display  of  force.  For 
this  the  point  and  edge  of  the  blade  should  be  of  the 
utmost  sharpness,  and  many  surgeons  are  careful  to  cut 
with  sawing  action,  and  to  cut  only  the  thinner  portions 
of  the  after-cataract.  Where  there  has  been  iritis  or 
irido-cyclitis  following  the  cataract  extraction,  leaving 
organized  deposit  and  more  or  less  adhesion  between  iris 
and  capsule,  it  is  not  safe  to  interfere  with  the  result  for 
some  little  time  after  the  complete  disappearance  of  ciliary 
injection.  An  irritation-free  interval  of  a  few  months  (two 
to  six)  is  laid  down  as  essential.  And  at  the  secondary 
operation  very  many  surgeons  endeavour  to  avoid  pull 
upon  the  iris  and  ciliary  body  by  dividing  the  membrane, 
often  together  with  iris,  by  de  Wecker's  or  other  irido- 
tomy  scissors,  introduced  through  a  small  corneal  or 
sclero-corneal  incision. 

The  question  of  glaucoma  following  upon  the  needling 
of  after-cataract  is  considered  later.  It  may  or  may  not 
be  of  inflammatory  origin.  It  is  enough  to  mention  here 
that  the  prophylaxis  in  this  respect  includes  some  of  the 
precautions  against  infection  and  against  the  relighting  of 
old  inflammatory  mischief.  And  one  is  careful  to  avoid  all 
unnecessary  churning  up  and  displacement  of  vitreous 
and  pull  upon  the  ciliary  body  and  iris.  And  quite  early 
treatment  does  not  appear  to  be  nearly  so  liable  to  cause 
plus  tension  as  later  treatment,  as  explained  below. 

micro-organisms  still  remaining  in  the  tissues  obtain  suitable  material 
for  their  growth  in  blood  and  lymph  resulting  from  the  slight 
traumatism,  and  develop  fresh  pathogenic  activity,  possibly  greater 
than  before. 


After^CompIications  33.1 

Knapp  says  :*  "  Those  operations  have  shown  the  greatest 
reaction — glaucoma  and  cyclitis — in  which  I  have  endeavoured 
to  cut  dense  cords  or  membranes  in  the  region  of  the  extraction 
scar,  the  most  vulnerable  part  of  the  aphakic  eye.  I  have, 
therefore,  avoided  disturbing  the  cicatricial  tissue  in  that 
region." 

The  only  things  in  a  needling  calculated  directly  to 
cause  or  predispose  to  detachment  of  retina  are  displace- 
ment and  breaking  up  of  vitreous,  and  adhesion  of  vitreous 
to  the  puncture.  In  discission  with  scissors  and  in 
extraction  of  opaque  capsule  there  may  be  also  loss  of 
vitreous.  The  complication  is  naturally  to  be  feared 
chiefly  in  highly  myopic  eyes  with  vitreous  opacities,  due 
either  to  previous  disease  of  the  eye  or  to  loss  of  vitreous 
during  the  cataract  extraction.  In  highly  myopic  eyes, 
already  predisposed  to  the  accident,  one  hesitates  in 
connecting  the  detachment  always  with  the  operative 
treatment. 

In  such  eyes  one  is  reluctant  to  perform  the  simplest 
capsulotomy  for  after-cataract.  Even  in  the  ordinary  run 
of  cases  the  bare  possibility  of  this  accident  weighs  against 
the  needlings  from  behind  through  the  vitreous,  which 
have  been  practised,  and  against  operations  in  which 
there  is  any  risk  of  loss  of  vitreous. 

Santos  Fernandes  f  reported  four  retinal  detachments 
following  the  tearing  of  after -cataract  by  needles.  Morrison 
Ray  j  related  a  case  of  immediate  detachment  on  needling. 
A  considerable  vitreous  loss  had  complicated  the  extraction 
operation. 

Discission  with  narrow  Graefe  or  Knife-Needle. 

General  Considerations. — A  correctly  performed  simple 
division  of  an  after-cataract  being  now  regarded  as  prac- 

*  Archives  of  Ophth.^  xxvii  (1898). 

t  Arch,  de  Oftal.  Hisp.-Amer.,  October,  1905. 

X  Ann.  of  Ophth.,  viii  (1899),  191. 


ZZ^  Cataract  Extraction 

tically  free  from  risk,  when  should  it  be  performed  ?  And 
in  which  cases  is  it  advisable  or  necessary  ?  These  two 
questions  are  linked  together.  For  according  to  the 
period  at  which  treatment  is  undertaken  the  problem  of 
the  selection  of  cases  presents  itself  variously. 

It  may  be  taken  as  settled  that  the  interval  between 
extraction  and  needling  should  be  as  short  as  possible. 
Some  surgeons  prefer  to  wait  until  the  eye  is  perfectly 
quiet — i.e.,  free  from  injection — before  interfering.  This, 
however,  is  by  no  means  necessary.  A  growing  number 
of  ophthalmologists  are  strongly  of  opinion  that  the  dis- 
cission should  be  done  as  soon  as  the  primary  wound  is 
sufficiently  firm  to  withstand  the  necessary  manipulation. 
Mayweg  operates  on  the  tenth  day,  Snellen  in  about  a 
fortnight,  de  Lapersonne  in  twelve  to  fifteen  days  in 
some  cases,  Haab  after  two  or  three  weeks,  Pagenstecher 
"  as  early  as  possible."  Czermak  made  twelve  days  the 
minimum  interval.  Knapp  recommends  treatment  within 
six  weeks.  In  Bombay  we  needled  generally  at  the  end 
of  ten  or  eleven  days.  In  practically  all  of  these  early 
needlings  the  eyes  were  still  more  or  less  congested.  Pro- 
vided the  iris  appears  bright  and  the  globe  is  free  from 
pain  and  tenderness,  the  presence  of  considerable  ciliary 
injection  and  of  moderately  copious  pigmented  deposit  on 
the  lens  capsule  need  cause  no  delay.  They  are  not  to  be 
regarded  as  signs  of  iritis,  which,  as  already  stated,  would 
necessitate  a  long  postponement.  Sometimes  we  had  to 
postpone  treatment  because  the  eye  was  still  quite  soft. 
This  was  mostly  in  cases  where  too  large  a  conjunctival 
flap  had  led  to  separation  of  the  sclero-corneal  wound, 
also  after  some  Czermak  operations.  But  we  operated 
(always  satisfactorily)  in  many  eyes  where  the  tension  was 
at  least  —  i,  and  where  the  knife-point  in  puncturing 
indented  the  globe.     Another  possible  cause  for  delay  in 


Aft  er^  Complications  333 

needling  is  the  occurrence  of  late  prolapse  of  iris,  or  the 
presence  of  any  small  prolapse  which  for  some  reason  was 
not  at  once  excised.  The  treatment  of  the  prolapse  should 
precede  that  of  the  after- cataract,  because  a  reversal  of 
this  procedure  would  introduce  the  risk  of  vitreous  escape 
on  the  removal  of  the  iris  prolapse. 

The  great  advantage  to  us  of  this  very  early  treatment 
was  that  it  could  be  carried  out  within  the  ordinary  period 
of  the  patients'  stay  in  hospital,  or  with  an  addition  of  one 
day  only.  Thus  it  was  not  allowed  to  reduce  the  number 
of  beds  available  for  major  operations,  and,  much  more 
important,  it  could  be  extended  to  nearly  every  patient 
needing  it.  It  was  done  as  a  matter  of  routine,  and  the 
patients  raised  no  objection.  Whereas  if  they  had  been 
discharged  and  asked  to  return  for  further  treatment, 
extremely  few  of  them  would  ever  have  been  seen  again, 
and  the  large  majority  of  them  would  thus  by  their 
ignorance  and  prejudice  have  been  deprived  of  the  benefit 
of  the  treatment.  And  the  comparatively  poor  results 
which  were  frequently  obtained  formerly  without  the 
secondary  needling  must  have  tended  to  discourage 
others  of  their  ignorant  cataractous  friends  from  seeking 
relief. 

Apart  from  all  this,  early  treatment  has  two  important 
recommendations,  (i)  The  capsule  being  now  mostly  of 
normal  or  nearly  normal  elasticity,  the  opening  made  in  it 
gapes  widely,  and  the  simplest  treatment  is  therefore 
effective.  Whereas  a  year  or  two  later  loss  of  elasticity  of 
the  membrane  might  render  a  more  complicated,  and  there- 
fore less  safe,  procedure  necessary  to  furnish  the  desired 
opening.  (2)  The  membrane  is  now  often  much  easier  to 
divide.  Any  lymph  deposits  and  remains  of  blood-clot  on 
the  capsule,  which  would  later  organize  partly  into  tough 
fibrous  tissue,  at   this   early   period   offer   no  resistance. 


334  Cataract  Extraction 

Hence  there  is  often  much  less  pull  upon  the  ciliary  body 
(and  upon  the  iris  if  there  are  posterior  synechiae)  than 
there  would  be  later. 

There  is  possibly  a  third  advantage  in  operating  quite 
early,  at  least  after  cataract  extraction  with  a  fairly  com- 
plete conjunctival  flap.  Even  where  there  is  no  visible 
separation  of  the  deep  wound  under  the  conjunctiva,  there 
is  probably  considerably  freer  filtration  through  the  wound 
than  there  will  be  later.  This  must  reduce  very  consider- 
ably the  possibility  of  plus  tension  being  excited  by  the 
needling.  This  may  largely  account  for  our  practically 
complete  freedom  from  trouble  in  this  respect  in  Bombay. 

The  drawbacks  to  operating  early  are  very  slight. 
Perhaps  the  most  noticeable  one  is  an  occasional  difficulty 
in  deciding  whether  a  given  case  requires  treatment  or 
not — whether  the  benefit,  present  or  future,  is  likely  to  be 
sufficient  to  repay  the  trouble.  Some  surgeons  adopt  a 
standard  of  visual  acuteness,  and  operate,  as  a  rule,  only 
when  the  result  from  the  extraction  is  below  the  standard. 
But  this  can  apply  only  to  later  needlings.  A  fortnight  or 
less  after  operation  it  may  be  difficult,  in  spite  of  ophthal- 
moscopic examination  of  fundus  and  of  membrane,  to 
determine  at  all  accurately  the  sources  of  any  defective 
visual  acuteness.  We  noticed  this  particularly  after  intra- 
capsular extractions  where  little  or  nothing  could  be  found 
to  account  for  defective  vision.  The  requirements  of  the 
individual  vary  so  greatly  with  occupation,  temperament, 
etc.,  that  no  fixed  standard  can  obtain  very  general 
application.  And  the  condition  of  the  fellow  eye  has  some 
bearing  upon  the  question.  Very  good  vision  in  it  renders 
interference  for  the  slighter  grades  of  opacity  superfluous. 
Or,  if  there  be  ripe  or  nearly  ripe  cataract  in  it,  one  may 
prefer  to  await  the  result  of  the  second  cataract  extraction, 
before  deciding  whether  any  treatment  for  after-cataract 


After^CompIications  335 

would  be  advantageous  or  advisable.  If  by  any  chance 
this  second  cataract  extraction  were  unsuccessful,  the 
question  of  subjecting  the  one  useful  eye  to  any  risk  would, 
of  course,  become  a  much  more  serious  one. 

In   early  treatment   one  is  forestalling  future  require- 
ments. Much  of  the  opacity  now  present  will  disappear,  and 
it  is  a  question  to  what  extent  later  capsular  degeneration 
and   folding  are  likely   to    interfere   with    vision.     Some 
operators  brush  the  difficulty  aside  by  needling  all  capsules 
except  where  the  patient  declines  the  operation,  or  where 
the  visual  improvement  is  likely  to  be  inappreciable  owing 
to  corneal  opacity  or  fundus  changes,  or  where  the  treat- 
ment  is    contra-indicated   by   high    myopia    or   vitreous 
opacities,  or  where  the  conditions  present  counsel  delay 
and  perhaps  more  complicated  procedure.  If  it  be  admitted 
that  simple  capsulotomy  is  invariably  harmless,  there  can 
be    no  very  serious  objection    to   extending   its  applica- 
tion a  little  unnecessarily.     But  it  is  more  scientific  to 
take  steps  to  learn  to  recognize  the  eyes  which  would 
never  require,  or  derive  the  slightest  benefit  from,  inter- 
ference.    A  systematic  examination  of  old  capsules  years 
after    cataract    extraction    reveals    in    many    cases    the 
posterior   capsule    still    absolutely   transparent    and   un- 
wrinkled.     In  such  an  eye  it  is  obvious  that  the  provision 
of  a  sufficiently  wide  opening  in  the  anterior  capsule,  at 
the  time  of  the  cataract  extraction,  has  met  the  whole 
needs  of  the  case.     My  own  somewhat  limited  observation 
has  led  me  to  associate  these  permanently  clear  posterior 
capsules  most  confidently  with  cataracts  operated  upon 
while  still  somewhat  unripe  or  barely  ripe.     In  Bombay 
slightly  less  than  a  third  of  our  cataract  extractions  were 
supplemented  by  early  needlings,  but  the  proportion  would 
have  been  higher  if  we  had  always  had  time  to  spare  for 
the  performance  of  the  needlings. 


o?)^  Cataract  Extraction 

Capsular  treatment  is  required  much  less  frequently 
after  cataract  extraction  in  which  anterior  capsule  has 
been  removed  with  forceps  than  when  it  has  been  simply 
divided  with  the  cystitome.  Very  many  of  our  need- 
lings  were  for  anterior  capsule  in  which  the  opening  for 
some  reason  was  narrow  or  eccentric  (Figs.  63-67). 
Treacher  Collins,  by  removing  anterior  capsule  with  the 
lens,  reduced  the  number  of  his  supplementary  capsule 
operations  to  4  per  cent.  One  must  here  recall  the  fact 
that  in  some  eyes,  as  already  mentioned,  the  treatment  of 
after-cataract  appears  too  dangerous  to  be  undertaken. 
Another  small  drawback  to  early  needling  is  that  occasion- 
ally it  causes  a  little  haemorrhage  into  the  anterior  chamber. 
One  may  feel  doubtful  whether  the  blood  comes  from  the 


Fig.  83. — Very  narrow  Graefe's  Knife,  suitable  for 
Discission. 

congested  sclerotic  or  from  the  stretched  (or  torn)  iris. 
And  at  this  early  period  the  pull  upon  iris  and  ciliary  body, 
in  scarcely  recognizable  minimal  grades  of  inflammation, 
is  apt  to  increase  the  number  of  small  inflammatory  re- 
actions, as  compared  with  those  one  would  meet  with  in 
later  treatment. 

The  operator  has  still  to  select  his  instrument.  The 
choice  lies  primarily  between  two  types,  the  one  repre- 
sented by  a  very  narrow  Graefe's  knife,  about  ^  millimetre 
in  breadth,  the  other  by  Knapp's  knife-needle.  The  long 
Graefe  blade,  of  which  only  a  portion  enters  the  anterior 
chamber,  is  intended  to  be  used  with  cutting  edge  directed 
backwards  only,  towards  capsule  and  iris.  The  short 
blade  of  the  knife-needle  is  introduced  completely  within 
the  chamber.     Its  round  stem  exactly  fills  the  corneal  or 


After^CompIications  2)o7 

sclero-corneal  puncture  made  by  the  blade,  and  permits  of 
free  rotation  of  the  blade  within  the  chamber  without 
leakage  of  aqueous.  The  Graefe's  knife  is  used  mostly  for 
making  a  single  long  cut  in  the  after-cataract.  It  may  be 
readily  swung  around  in  the  sclero-corneal  puncture  to 
make  a  second  incision  at  an  angle  to  the  first  one.  The 
two  cuts  necessarily  converge  towards  the  puncture,  and 
the  angle  between  them  cannot  be  large,  but  it  is 
sufficient  for  all  needs.  The  knife-needle,  on  the  other 
hand,  allows  of  a  crucial  or  T-shaped  incision,  since  a 
section  may  be  made  with  the  blade  on  the  flat  at  right 
angles  to  that  made  with  the  cutting-edge  backwards.  A 
much  more  important  difference  lies  in  the  fact  that  the 
long-bladed  instrument  is  suited  for  cutting  by  free  sawing 


Fig.  84. — Knife-Needle. 

movements,  whereas  the  short  blade  is  adapted  for 
dividing  the  somewhat  mobile  elastic  membrane  only  by  a 
sweeping  cut,  or  by  very  restricted  sawing  movements. 
The  blade  of  Knapp's  medium-sized  instrument,  which  he 
recommends  for  most  after-cataracts,  is  4^  milhmetres 
long,  but  only  about  half  of  the  blade  has  a  sharp  cutting 
edge.  The  portion  nearest  the  stem  does  not  admit  of 
being  sharpened.  Consequently  any  but  the  most  re- 
stricted to-and-fro  movement  is  apt  to  bring  the  blunt 
portion  of  the  edge  into  action,  tearing  rather  than  cutting, 
and  pulling  upon  the  membrane  and  its  attachments. 
And  we  have  doubted  whether  the  Knapp's  needles,  even 
when  quite  new  from  a  well-known  London  maker,  were 
quite  so  sharp  as  our  old  Graefe's  knives.  (We  have 
used   very  old   cataract  knives,   ground   down  to  a  suit- 

22 


33^  Cataract  Extraction 

able  width,  and  tapering  gradually.  These  blades  are 
thin,  and  easily  sharpened.)  Either  on  this  account  or 
because  of  the  difference  in  mode  of  cutting,  we  un- 
doubtedly had  more  reactions  after  operating  with  the 
cutting  needle  than  with  the  straight  knife.  The  latter, 
with  free  sawing  action,  undoubtedly  furnished  satisfactory 
capsular  openings  with  a  minimum  of  pressure.  One  is 
apt,  however,  unconsciously  to  enlarge  the  (sclero-corneal) 
puncture  while  dividing  the  capsule  with  the  long  blade. 
In  theory  it  should  be  easy  to  avoid  this  by  keeping  the 
back  of  the  blade  pressed  against  the  tissues  in  the  punc- 
ture. But  in  practice,  with  one's  attention  given  up  to  the 
capsular  division,  this  precaution  is  not  always  taken.  In 
Bombay  this  enlargement  of  the  sclero-corneal  puncture 
during  sawing  occurred  not  infrequently.  On  this  account, 
and  because  of  a  liability  to  pass  the  long  blade  deeply  into 
the  vitreous  unwittingly  while  sawing,  some  operators  have 
quite  unnecessarily  discarded  the  long-bladed  instrument 
after  giving  it  a  trial.  A  subconjunctival  puncture  appears 
to  be  quite  an  adequate  guarantee  against  evil  consequences 
from  vitreous  exposure.  The  knife  may  enter  deeply  because 
there  is  nothing  in  the  shape  of  the  blade,  at  some  little 
distance  from  its  point,  to  show  the  depth  of  penetration. 
I  have  never  had  personal  acquaintance  with  any  harmful 
result  of  this  deep  penetration.  The  vitreous  is  simply 
incised,  and  not  ploughed  up,  by  the  knife. 

For  general  use  in  hospital  practice,  especially  far  away 
in  India,  a  point  against  the  Knapp's  needle  is  its  limited 
period  of  usefulness,  owing  to  the  disproportion  between 
blade  and  stem  brought  about  by  repeated  resetting, 
already  alluded  to. 

The  long  Graefe's  blade  may  be  used  to  divide  matted 
tissues — iris,  organizing  exudation,  and  capsule — where 
the  pupil  is  occluded  after  iritis  and  irido-cyclitis.    It  may 


After^CompIications  339 

also  be  expected  to  cut  some  tough  capsules  which  seem 
likely  to  prove  too  resistant  for  Knapp's  needle. 

The  lighting  is  of  some  importance,  ordinary  daylight 
being  insufficient  to  enable  one  to  see  the  membrane 
clearly  unless  it  be  unusually  opaque.  A  small  electric 
hand  lamp  is  commonly  made  use  of,  or,  when  this  is  not 
available,  some  arrangement  for  focussing  the  light  from  a 
gas  or  oil  lamp.  An  acetylene  lamp  has  been  used  by 
Koster  and  van  Geuns.*  Focal  illumination  in  a  dark 
room  affords  the  clearest  view  of  the  after-cataract,  and 
some  surgeons  operate  always  in  a  dark  room.  In  Bombay 
we  found  that  bright  daylight  was  sufficient  for  the 
performance  of  the  needling  after  examination  of  the  con- 
ditions present  and  of  the  procedure  required,  carried  out 
in  the  dark  room  with  dilated  pupil.  Ed.  Jackson  uses 
also  a  binocular  magnifier,  with  a  working  distance  of 
6  inches. 

A.  Discission  with  the  narrow  Graefe's  Knife. 

The  line  of  the  incision  being  determined  within  broad 
limits  by  the  position  at  which  the  narrow  knife  is  entered, 
it  is  convenient  to  puncture  at  the  outer  or  lower  and 
outer  t  margin  of  the  cornea.  One  is  thus  enabled  to 
operate  with  the  lids  separated  merely  by  the  assistant's 
fingers.  It  is  well,  as  a  rule,  to  avoid  the  use  of  a  speculum 
for  early  needlings.  For  (i)  the  union  of  the  wound  is  not 
yet  very  firm,  and  is  therefore  not  suited  to  withstand 
much  strain,  such  as  might  be  brought  to  bear  by  forcible 
contraction  of  the  lids  upon  the  speculum.  And  (2)  the 
Meibomian  glands  at  this  period  are  commonly  filled  with 

*  Med.  Tijdsch.  v.  Geneeskunde.,  No.  12,  1904. 

t  In  early  needling  the  puncture  cannot  be  much  above  the 
horizontal  corneal  meridian,  owing  to  the  proximity  of  the  healing 
wound. 

22 — 2 


340 


Cataract  Extraction 


secretion,  evidently  owing  to  the  prolonged  period  of 
inactivity  of  the  eyelids  under  the  bandage.  The  pressure 
of  the  arms  of  the  speculum  therefore  forces  out  a  good 
deal  of  Meibomian  secretion,  and  this  is  carried  over  the 
surface  of  the  globe  by  any  irrigating  fluid  used,  unless  the 
glands  are  well  emptied  beforehand  by  squeezing.  And 
one  has  to  be  careful  in  the  manipulation  of  the  lids 
required  for  emptying  the  glands,  not  to  allow  one's  fingers 
to  slip,  so  as  possibly  to  press  upon  the  globe.  Thus  in 
early  needlings  the  speculum  is  seldom  used  except  where 


Fig.  85. — Discission  of  After  Cataract  with  the  narrow 
Graefe's  Knife. 

a  vertical  or  nearly  vertical  section  of  the  membrane  is 
thought  advisable.*  It  is  necessary  in  this  case,  because 
with  finger  depression  of  the  lower  lid  the  assistant's 
finger  would  interfere  with  the  correct  placing  of  the  knife. 
(The  use  of  McGillivray's  lid  depressor  might  perhaps  get 
over  this  difficulty.)  For  a  vertical  section  it  is  necessary 
that  the  patient  shall  rotate  the  eye  well  upwards,  and  we 
found  our  patients  often  rather  stupid  over  this — much 

♦  In  Fig.  85  the  speculum  is  shown  in  use  for  an  almost  horizontal 
division  of  after-cataract,  but  this  is  merely  for  the  purpose  ,of  the 
photograph. 


After' Complications  341 

more  so  than  at  the  time  of  the  major  operation.  All  this 
applies  only  to  early  discission  while  the  wound  is  weak, 
the  lid  margins  unclean,  and  the  patient  nervous. 

The  conjunctival  sac  is  washed  out  with  perchloride 
before  the  cocain  instillation,  as  for  an  extraction  opera- 
tion. Care  is  taken  in  this  also  not  to  press  upon  the  eye 
and  not  to  evert  the  upper  lid,  if  the  extraction  has  only 
recently  been  performed.  (Mucus  resulting  from  the 
perchloride  irrigation  may,  if  desired,  be  removed  with  a 
curette.)  The  pupil  has  been  already  dilated  for  the  dark- 
room examination,  if  not  still  dilated  from  the  after-treat- 
ment of  the  cataract  extraction. 

In  performing  early  discissions,  if  ciliary  injection  be 
still  present,  the  anaesthesia  produced  by  cocain  alone 
is  sometimes  insufficient.  Pain  is  felt  chiefly  when  the 
ciliary  attachments  are  pulled  upon  in  cutting  the  capsule, 
and  it  may  be  so  marked  as  to  prevent  the  making  of  a 
long  incision.  Therefore  it  is  a  sound  rule  in  early 
needlings  always  to  use  some  adrenalin  preparation  before 
or  with  the  cocain,  for  the  more  complete  anaesthesia  which 
is  obtainable  with  blanching  of  the  eye.  Should  adrenalin 
not  have  been  instilled,  and  should  the  patient  show  signs 
of  feeling  the  insertion  of  the  speculum  or  the  seizure  of  the 
conjunctiva  by  the  fixation  forceps,  it  will  be  well  to  desist 
for  five  or  ten  minutes,  to  obtain  the  help  of  adrenalin. 

The  globe  being  fixed  with  forceps  at  the  nasal  side,  the 
point  of  the  knife  is  engaged  in  the  loose  ocular  conjunctiva 
at  a  distance  of  about  2  millimetres  from  the  site  of  the 
intended  puncture — downward  and  outward  from  the 
common  outer  puncture.  (In  some  of  our  old  Indian 
patients  the  conjunctiva  close  to  the  cornea  about  its 
horizontal  meridian — the  most  exposed  part  of  the  con- 
junctiva— is  fixed  by  old  fibrous  changes,  rendering  the 
horizontal  meridian  an  unsuitable  site  for  puncture.)    The 


342  Cataract  Extraction 

conjunctiva  is  then  pushed  up  in  a  fold  to  the  corneal 
margin,  and  the  point  of  the  knife,  directed  towards  the 
centre  of  the  pupil,  pushed  through  the  sclerotic  |  to 
I  millimetre  from  the  corneal  boundary,  to  enter  the 
anterior  chamber.  In  making  this  puncture  the  back  of 
the  blade  is  forwards,  towards  the  operator,  and  not 
downwards,  as  shown  in  the  figure. 

The  point  of  the  knife  is  passed  inwards  or  upwards  and 
inwards  across  the  centre  of  the  pupil  to  the  far  side  of  the 
dilated  pupil  or  coloboma,  and  there  thrust  through  the 
capsule  by  depressing  the  point  slightly  and  continuing  its 
onward  movement  a  little  behind  the  iris.  The  movement 
of  the  blade  is  then  reversed.  A  single  withdrawal  move- 
ment may  suffice  to  make  a  long  incision  through  a  thin 


Fig.  86.— Branched  Capsular  Incision  made  with  the 

NARROW   GRAEFE'S   KNIFE. 

capsule,  and  the  margins  of  the  slit  may  be  seen  to  separate 
widely,  providing  a  broad  perfectly  black  central  space. 
Much  more  commonly  some  to-and-fro  sawing  movement 
of  the  knife  is  required  to  divide  the  whole  or  greater  part 
of  the  extent  of  the  visible  membrane.  The  instrument 
should  be  held  lightly,  to  avoid  all  unnecessary  pressure 
upon  the  membrane,  and  the  blade  must  not  be  allowed  to 
penetrate  more  deeply  than  necessary  into  the  vitreous. 
But  the  handle  of  the  instrument  may  have  to  be  raised  a 
little  for  sawing  close  to  the  near  side  of  the  pupil,  lest  in 
the  sawing  movements  the  sclerotic  be  also  incised. 

The  long  slit  in  the  capsule  usually  opens  widely.  The 
blade  is  withdrawn,  and  the  small  operation  is  at  an  end. 
If  the  puncture  has  not  been  unintentionally  enlarged,  and 


After^CompIications  343 

if  the  vitreous  has  not  been  entered  too  deeply,  there 
should  be  no  considerable  leakage  of  aqueous  and  no 
appearance  of  vitreous  in  the  puncture. 

In  a  few  early  needlings  where  the  opacity  represents 
the  old  capsular  thickening  of  an  overripe  cataract,  and  in 
a  still  larger  proportion  of  later  needlings,  where  degenera- 
tion of  the  capsule  has  reduced  its  elasticity,  or  where  the 
capsule  is  more  or  less  covered  by  fibroid  tissue,  the  edges 
of  even  a  long  opening  do  not  separate  widely.  It  is  usually 
a  simple  matter  then  to  swing  the  point  around  without 
withdrawing  the  blade,  and  to  push  it  onwards  again  to 
puncture  the  membrane  afresh  at  a  spot  2  millimetres  or 
more  from  the  opening  already  made,  and  so  to  make  a 
short  branch  incision  to  join  the  original  one. 

This,  in  my  experience,  may  be  relied  upon  to  provide  a 
sufficiently  wide  opening.  The  tongue  of  capsule  between 
the  two  cuts  retracts  or  becomes  displaced.  A  few  times, 
when  dissatisfied  with  a  transverse  opening,  I  have  imme- 
diately punctured  afresh  below  the  cornea,*  and  added  a 
vertical  incision  to  make  the  whole  T-shaped.  One  is 
tempted  often,  instead  of  puncturing  afresh,  to  attempt  to 
widen  a  rather  narrow  slit  in  a  thin  membrane  by  sweep- 
ing the  blade  around  in  it.  One  is  tempted  especially  to 
push  aside  a  sheet  of  quite  inelastic  membrane,  in  order 
that  the  advance  of  vitreous  into  the  gap  may  keep  it 
open.  Though  often  effective,  at  least  for  the  time  being, 
it  is  scarcely  correct  procedure  to  do  anything  calculated 
to  displace  vitreous.  But  even  the  second  puncture  of  the 
membrane,  whether  made  by  swinging  the  point  around 
or  through  a  fresh  sclero-corneal  insertion,  is  not  free  from 
objection  on  this  account.  The  backward  displacement 
of  the  membrane  produced  by  the  point  of  the  knife  in 

*  This  second  incision  might,  of  course,  have  been  deferred  for 
some  days  if  for  any  reason  this  had  been  thought  advisable. 


344  Cataract  Extraction 

puncturing  afresh,  with  the  cutting  edge  directed  back- 
wards, must  force  some  vitreous  through  the  sHt  already 
made  into  the  anterior  chamber.* 

Provided  a  wide  opening  is  secured,  the  meridian  in 
which  it  is  made  usually  matters  nothing.  The  width  of 
the  gap  depends  very  largely  upon  its  length.  If  only  a 
rather  short  single  cut  were  to  be  made,  it  would  have  to 
be  vertical  or  inclined  downward  and  inward.  The  loca- 
tion and  direction  of  the  incisions  are  by  many  surgeons 
arranged  to  avoid  tough  bands  of  tissue,  but  this  applies 
rather  to  old  after-cataracts  than  to  recent  ones,  and  to 
the  use  of  Knapp's  knife-needle  rather  than  to  the  use  of 
the  narrow  Graefe's  knife.  In  operating  with  the  latter, 
deposits  of  fibrin,  and  even  old  fibrous  bands,  can  be  sawn 
through  safely  and  readily,  and  their  tendency  to  later 
retraction  may  be  relied  upon  to  widen  the  gap.  The  line 
of  the  incision  may,  therefore,  at  times  be  arranged  to 
cross  any  dense  band  at  right  angles.  Where  the  pro- 
jecting angles  of  the  iris  at  the  coloboma  are  adherent  to 
the  capsule  one  often  prefers  to  cut  between  them,  to 
utilize  their  lateral  pull  (under  atropin)  upon  the  edges  of 
the  slit.  Hence,  one  not  infrequently  has  to  cut  vertically, 
inserting  the  knife  (subconjunctivally)  below  the  cornea, t 
and  passing  its  point  well  up  in  the  coloboma.  Rarely 
some  displacement  of  the  line  of  section  may  be  necessary 
on  account  of  corneal  leucoma. 

Occasionally,  in  eyes  fit  for  early  needling  the  anterior 
chamber  is  still  rather  shallow.     There  appears  to  be  still 

*  There  is  not  the  same  objection  to  a  second  perforation  of  the 
membrane  with  the  flat  of  the  blade  parallel  to  the  iris,  as  is  done  with 
Knapp's  needle.  Therefore  the  latter  instrument  is  preferable  for 
double  cuts ;  some  increase  of  the  pull  upon  the  ciliary  body,  by  loss 
of  the  sawing  action,  being  probably  less  to  be  feared  than  displace- 
ment of  vitreous. 

t  Fixation  forceps  applied  at  the  inner  side  of  the  cornea,  as  for  the 
transverse  cuts. 


After^CompIications  345 

some  leakage  through  the  healing  wound,  but  not  so 
much  as  to  make  the  globe  too  soft  for  operation.  Some 
care  is  needed  to  direct  the  point  of  the  knife  slowly 
through  sclerotic  and  cornea  into  the  angle  of  the  chamber. 
The  puncture  is  easier  in  these  eyes  with  a  Knapp's 
needle,  as  the  blade  can  be  inserted  on  the  flat.  These 
have  been  the  only  eyes  in  which  I  have  ever  felt  that 
there  was  any  real  (though  very  small)  advantage  in  using 
an  instrument  which  could  be  rotated  on  its  axis. 

Many  of  our  patients  were  sent  out  of  hospital  with 
the  eye  bandaged  up  for  a  day.  For  patients  kept  in 
hospital  the  wire  shade  should  suffice. 

Complications. 

K,  At  the  time. — i.  I  failed  to  divide  one  extraordinarily 
elastic  membrane. 

The  tissue  was  scarcely  at  all  opaque,  but  a  good  deal 
folded.  And  since  the  attempt  at  division  produced  a  reaction 
lasting  several  days,  I  did  not  try  again. 

I  refrained  altogether  from  interference  with  another 
peculiar  capsule,  fearing  the  same  trouble,  or  possibly  detach- 
ment of  retina  in  case  the  discission  were  accomplished.  It 
was  in  a  girl,  after  linear  extraction.  The  lens  had  been 
transparent,  but  operation  had  been  undertaken  for  myopia 
and  for  a  small,  dense  posterior  polar  opacity.  This  opaque 
patch  was  left  in  the  centre  of  a  distinctly  tremulous  transparent 
posterior  capsule. 

2.  Rarely  a  tough  membrane  may  tear  near  its  inner,  or 
upper  and  inner,  attachment  when  the  pressure  of  the 
knife  is  placed  upon  it  to  perforate  it.  This  may  be 
partly  due  to  a  slightly  blunt  knife,  or  to  the  application 
of  too  much  backward  pressure  with  too  little  onward 
movement  of  the  blade.  Otherwise  it  indicates  that  the 
case  would  have  been  better  dealt  with  by  the  double 
needle  operation,  or  more  complicated  procedure.     The 


34^  Cataract  Extraction 

large  central  leaf  may  often  be  considerably  displaced 
outwards  and  downwards  by  the  knife,  at  the  cost  of 
only  moderate  disturbance  of  vitreous ;  but  usually  it 
springs  back  sufficiently  to  cover  the  centre  of  the  pupil. 
It  is  not  sound  practice  to  make  repeated  attempts  to 
depress  the  membrane  in  the  vitreous.  Should  the  vision 
obtained  through  the  irregular  and  eccentric  opening  be 
insufficient,  the  offending  membrane  may  be  extracted  later 
or  divided  by  scissors,  though  with  almost  certain  loss  of 
some  vitreous. 

3.  In  a  small  percentage  of  cases  slight  haemorrhage 
occurs.  Next  day  a  little  blood  may  be  found  at  the 
bottom  of  the  anterior  chamber,  with  some  turpidity  of 
aqueous.  The  reduction  in  vision  thus  produced  is  very 
transient.  This  complication  occurred  in  one  of  our  dis- 
cissions which  was  not  at  all  *  early.' 

B.  Later, — i.  Very  occasionally  either  a  repetition  of 
the  same  operation  at  a  different  angle,  or  a  tearing  apart 
with  two  needles,  may  be  needed  for  an  inelastic  capsule, 
the  slit  in  it  having  failed  to  remain  sufficiently  open. 
This  is  especially  likely  to  happen  where  the  cataract  has 
been  Morgagnian. 

2.  Inflammatory  reaction  should  be  rare,  and  should 
yield  quickly  to  treatment. 

The  only  acute  reaction  noted  in  Bombay  of  late  years  was 
in  a  case  where  the  cataract  was  of  traumatic  origin,  and 
where  some  iritis  had  followed  the  original  injury.  The 
reaction  subsided  in  ten  days,  with  satisfactory  improvement 
in  vision. 

In  another  patient  early  discission  was  followed  by  chronic 
nodular  iritis,  lasting  a  few  months.  It  was  probably  excited 
more  by  the  extraction  operation  than  by  the  needling.  The 
eye  had  been  inflamed  several  years  before.  And  the  recru- 
descence of  apparently  tubercular  mischief  after  so  long  an 
interval  was  somewhat  interesting.     There  was  no  evidence  of 


After 'Complications  347 

tubercle  elsewhere.  The  nodules,  three  in  number,  which 
formed  in  the  lower  part  of  the  iris  subsided,  together  with  the 
iritis,  leaving  the  capsular  opening  sufficiently  wide  and  clear 
for  very  fair  vision. 

Apart  from  these  cases  only  a  few  trifling  reactions  have 
occurred  in  our  practice,  passing  off  in  a  few  days  under 
treatment  by  atropin  drops,  with  perhaps  warm  fomenta- 
tions. 

By  the  subconjunctival  puncture  we  have  been  secure 
against  fresh  infections,  such  as  might  lead  to  suppuration. 
Once,  years  ago,  I  had  a  panophthalmitis  after  puncturing 
through  the  cornea.  Vitreous  had  entered  the  small 
wound.  Da  Gama  Pinto,  puncturing  through  the  cornea 
with  a  narrow  Graefe's  knife,  reported  nine  incarcerations 
of  vitreous  in  198  discissions.  In  four  of  these  eyes  sup- 
puration occurred,  and  two  of  the  eyes  were  lost. 

In  eyes  affected  by  chronic  uveitis,  whether  in  any  way 
dependent  upon  the  secondary  operation  or  not,  the  cap- 
sular opening  may  gradually  become  occluded  by  in- 
flammatory deposit.  Some  rare  instances  of  membrane 
formation  in  the  capsular  opening  have  been  seen  in  eyes 
quite  free  from  irritation  (some  of  them  highly  myopic).* 

3.  I  can  certify  that  after  nearly  all  of  our  opera- 
tions for  after-cataract  in  Bombay  of  late  years,  and 
certainly  in  all  where  there  was  the  slightest  suspicion  of 
trouble,  the  tension  of  the  eye  was  tested.  It  was  only 
once  found  a  little  elevated,  and  this  rise  disappeared  in  a 
few  days  without  treatment.  We  performed  251  early  need- 
lings,  in  addition  to  33  late  needlings  within  the  last  fifteen 
months  of  my  work  in  Bombay. 

McGillivray,!  impressed  with  the  importance  of  cutting  by 
sawing  movements,  has  designed  a  curved  knife-needle  with 

*  A.  von  Hippel,  A.f.  O.,  xlix,  2,  387. 
t   Trans.  Oph.  Soc,  xxvii  (1907),  108. 


34^  Cataract  Extraction 

long  convex  cutting  edge  and  with  cylindrical  stem.  The 
incision  in  the  membrane  is  made  entirely  with  the  convex 
edge.  He  prefers  an  oblique  incision  from  above,  downwards 
and  a  little  inwards. 

Schnabel  *  used  either  a  narrow  Graefe's  knife,  or  a  similar 
blade,  sharpened  at  both  edges  for  8  millimetres  from  its 
point.  The  introduction  and  the  cutting  were  done  with  the 
flat  of  the  blade  parallel  to  the  iris. 


B.  Operation  with  Knapp's  Knife- Needle. 

Knapp  prefers  the  knife-needle,  "because  needles  cutting 
on  both  sides  can  for  equal  sizes  not  be  made  so  sharp. "t 
The  straight  instrument  is  preferred  because  "  curved 
needles  are  difficult  to  introduce  through  the  cornea,  and 
still  more  so  through  the  capsule.  .  .  .  The  straight  point 
transfixes  the  membrane  with  greater  ease,  less  pressure, 
and  therefore  less  tearing  at  the  ciliary  processes."  If  there 
are  no  special  indications  he  inserts  the  needle,  with  cutting 
edge  backwards,  in  the  horizontal  meridian  of  the  cornea 
3  millimetres  from  its  margin.  A  horizontal  incision  4  or 
5  millimetres  long  is  made  in  the  capsule.  And  then  with 
the  needle  rotated  to  present  the  cutting  edge  downwards 
the  membrane  is  transfixed  above,  and  a  short  vertical  cut 
is  made  downwards  to  join  the  horizontal  incision.  The 
addition  of  a  similar  short  vertical  cut  below  provides  a 
crucial  opening.  The  first  cut  is  made  by  a  simple  with- 
drawal movement  of  the  instrument,  the  secondary  ones 
by  sweeping  action.  The  incisions  have  to  go  through  the 
softest  parts  of  the  capsule ;  hard  and  inelastic  bands  and 
patches  should  not  be  attacked.  "  Two  incisions  may  suffice, 
in  the  shape  of  a  T,  or  the  one  crossing  the  other  at  an 
acute  angle." 

*  Elschnig,  Wiener  Kl.  Wschr.^  ix  (1896),  No.  53. 
t  Norris  and  Oliver's  '  System,'  iii,  812. 


After^Com  plications  349 

.  It  may  well  be  that  the  central  crucial  or  T-shaped 
opening  with  Knapp's  needle  is  particularly  suited  to  his 
work.  The  untouched  central  capsule,  after  simple  ex- 
traction with  *  peripheric  splitting '  of  the  capsule,  must 
give  fairly  uniform  and  accurate  results  from  comparatively 
short  incisions.  On  the  other  hand,  the  central  and  para- 
central adventitious  bands,  lying  along  the  margins  of  the 
ordinary  central  capsular  opening,  as  in  our  work,  suggest 
the  need  for  freer  division.  Knapp  tabulated  the  vision  of 
seventy  eyes  before  and  after  needling.  The  amount  of 
vision  was  more  than  doubled  by  the  operation.  It 
averaged  slightly  less  than  one-fifth  before,  two-fifths  after 
treatment. 

Should  a  corneal  puncture  be  used,  after  Knapp,  and  should 
vitreous  enter  it,  any  hanging  thread  would  be  cut  off.  Similar 
threads  unconnected  with  vitreous,  and  representing  fila- 
mentary keratitis,  have  been  mentioned  in  connexion  with 
discission  punctures  (see  Haab,  '  Operative  Ophthalmology,' 
p.  i68). 

Ed.  Jackson,*  using  Knapp's  knife  -  needle,  makes  two 
incisions,  meeting  one  another  in  the  form  of  a  V,  each  made 
by  sweeping  movement.  The  blade  is  inserted  on  the  flat  and 
kept  so — i.e.,  with  cutting  edge  downwards,  not  backwards. 
The  puncture  is  at  the  limbus,  down  and  out.  The  nearer  limb 
of  the  V  is  cut  first.  Stress  is  laid  upon  the  mechanical  advan- 
tage of  the  peripheral  insertion  in  the  longer  leverage  obtained. 
"  The  same  length  of  sweep  of  the  knife  edge  will  be  obtained 
with  one-half  of  the  twisting  of  the  shank  in  the  puncture — 
less  than  one-half  of  damage  to  adjoining  tissues."  The  short 
sweep  obtainable  through  Knapp's  corneal  puncture  may 
accomplish  almost  nothing,  owing  to  elasticity  of  the  capsule, 
and  owing  at  times  to  the  near  approach  of  the  capsule  to  the 
cornea  through  leakage  of  aqueous  beside  the  needle.  This 
leakage  may  occur  with  a  perfectly  proportioned  instrument, 
owing  to  the  pressure  exerted  upon  the  rigid  corneal  tissue  in 
the  swinging  movements  of  the  needle.     With  the  peripheral 

*  Arch,  of  Ophth;  xxxv  (1906),  127. 


350  Cataract  Extraction 

insertion  there  may  be  some  slight  difficulty  in  accurately 
locating  the  capsule  puncture,  but  the  difficulty  is  too  trifling 
to  be  of  practical  importance. 

Czermak*  used  Knapp's  needle,  inserted  at  the  limbus,  to 
make  usually  a  single  long  incision  by  sawing  action.  The 
opening  was  made  T-shaped  in  inelastic  capsules. 

Kuhnt  t  uses  Knapp's  needles  with  stems  bent  to  admit  of 
their  (subconjunctival)  insertion  at  any  selected  point  of  the" 
limbus.  He  also  is  satisfied  with  a  single  incision  7  to  8  milli- 
metres long  in  thin  capsules.  For  a  T-shaped  opening  he 
uses  two  needles,  inserted  rather  close  together,  with  cutting- 
edges  in  opposite  directions.  The  second  portion  of  the 
incision  is  made  by  the  two  edges  approximated  to  cut  with 
scissor  action.  Where  there  are  posterior  synechise,  the  two 
cutting  needles  are  made  to  penetrate  the  membrane  together 
centrally,  and  cut  in  opposite  directions  towards  the  periphery. 
Special  forms  of  incision  are  designed  also  for  cases  in  which 
there  has  been  loss  of  vitreous,  and  where  the  capsule  has 
healed  in  the  wound.  In  an  experience  of  about  six  hundred 
discissions  there  were  no  losses,  and  the  vision  improved  in 
nearly  every  case.  In  the  last  hundred  cases  there  was  a 
improvement  in  visual  acuity  from  23*8  to  58*7. 

De  Lapersonne  and  Poulard  j  have  divided  secondary 
membranes  from  behind  by  a  sickle-shaped  needle  introduced 
above,  i  to  2  millimetres  above  the  summit  of  the  flap  made 
in  the  extraction  operation.  They  operated  from  the  eighth  to 
the  fifteenth  day  after  the  extraction. 

Posterior  scleral  discission  was  practised  largely  by  the  old 
Vienna  school,  and  later  by  Da  Gama  Pinto.§  A  cutting 
needle  or  narrow  knife  was  inserted  in  the  region  of  the  ora 
serrata,  6  to  8  millimetres  behind  the  limbus,  and  passed 
forward  through  the  vitreous  to  transfix  the  capsule  at  the 
near  side.  The  point  of  the  instrument  was  then  pushed  on 
parallel  to  the  membrane,  and  again  passed  through  the 
capsule  from  in  front  at  the  far  side  of  the  pupil,  and  the 
division  completed   by   sawing   movements.     In  the  light  of 

*  Die  Au^en.  Op.,  S.  864. 

t  Zeitsch.f.  A.,1  (1899),  151  and  260. 

X  Tenth  International  Congress,  Lucerne,  1904. 

§  Ann.  d'Ocul.,  cxvii  (1897),  22. 


After^CompIications  351 

what  has  been  said  above  upon  unnecessary  disturbance  of 
the  vitreous,  further  detailed  description  of  the  procedure  and 
discussion  of  the  suggested  dangers  appears  superfluous — 
risk  of  haemorrhage  into  the  vitreous,  dislocation  of  the  capsule 
into  the  vitreous,  danger  of  detachment  of  retina  from  healing 
of  vitreous  in  the  puncture.  Pinto  in  133  operations  improved 
the  vision  in  ninety-five,  and  reduced  it  in  seven  cases.  In 
three  cases  glaucoma  followed.  Noyes*  considers  that  this 
treatment  should  be  adopted  one  to  three  months  after  the 
original  operation,  where  a  small  and  undilatable  pupil 
(whether  simply  rigid  or  bound  down  by  synechiae)  does  not 
provide  sufficient  room  for  ordinary  discission  of  the  capsule 
through  the  pupil.  In  such  cases,  however,  no  particular 
harm  follows  limited  incision  of  the  iris. 

Opinions  upon  the  treatment  of  the  thicker,  denser,  and 
inelastic  forms  of  after-cataract,  including  those  resulting 
from  iritis  and  irido-cyclitis,  vary  greatly.  All  of  these 
after- cataracts  are  divisible  primarily  into  those  which  can, 
and  those  which  cannot  be  cut  with  a  narrow  Graefe's 
knife.  The  latter  membranes  may  be  torn,  or  divided  with 
scissors,  or  extracted.  The  former  group  includes  the 
results  of  iritis  and  irido-cyclitis  after  cataract  extraction, 
even  to  complete  occlusion  of  pupil  and  coloboma,  and 
matting  together  of  iris  and  capsule  by  organized  exuda- 
tion. 

I  have  been  in  the  habit  of  practising  simple  division  of 
such  membranes  with  the  narrow  knife,  cutting  the  iris 
freely  together  with  the  tissues  behind  it  when  necessary. 
This  is  not  commonly  considered  sound  practice,  for  the 
pull  upon  the  ciliary  body  is  considered  to  be  too  great. 
Further,  on  this  account  only  one  incision  must  be  made 
at  a  time.  If  there  be  dense  occlusion  of  pupil,  the  single 
incision  in  the  matted  tissue  does  not  gape  well.  A 
second  incision  at  right  angles  to  the  first  may  be  needed 

*  Medicine^  January,  1900. 


35-  Cataract  Extraction 

to  make  the  whole  T-shaped,  as  soon  as  the  eye  has 
become  perfectly  '  quiet '  after  the  first  attempt.  My  ex- 
perience with  fully  occluded  pupils  has  been  small.  So  far 
I  have  not  seen  any  bad  results  from  this  treatment.  The 
openings  have  not  become  closed  by  blood-clot  or  lymph, 
as  they  are  said  to  do  sometimes.  I  have  made  the 
primary  incision  vertical,  because  it  has  sometimes  sufficed 
alone,  even  though  narrow.  But  it  is  usually  made 
horizontal  to  obtain  the  benefit  of  the  vertical  pull  of  the 
stretched  iris.  It  is  questionable  whether  the  complete 
division  with  a  really  sharp  knife  entails  any  more  pull  upon 
the  ciliary  attachments  than  any  other  mode  of  cutting,  for 
in  order  to  be  cut  with  scissors  the  matted  tissues  must  be 
first  pierced,  to  allow  of  a  blade  of  the  instrument  being 
inserted  behind  the  membrane.  If,  as  is  usual,  this  puncture 
be  made  with  the  keratome  or  scissor  point,  this  must 
almost  certainly  need  as  much  pressure  upon  the  membrane 
as  the  long  incision  with  the  much  sharper  narrow  knife. 
And  the  scissor  operation  has  the  serious  drawback  of 
very  frequently  allowing  vitreous  to  enter  the  wound,  and 
perhaps  to  escape  through  it.  This  disadvantage  is  not 
shared  by  the  simpler  operation.  A  fair  result  may  be 
hoped  for  by  operation  after  severe  irido-cyclitis,  provided 
the  tension  of  the  globe  has  not  been  much  reduced,  and 
provided  the  field  of  projection  of  light  is  good.  In  testing 
this  field  allowance  must  be  made  for  extreme  upward 
displacement  of  the  pupil.  One  is  surprised  to  note  how 
light  penetrates  through  a  densely  occluded  pupil. 

Haab  *  supports  the  iris  by  two  Bowman's  needles,  and  cuts 
between  them.  The  needles  are  introduced  one  after  the 
other  from  the  temporal  side  through  cornea  and  iris,  parallel 
to  each  other  and  3  millimetres  apart.  They  are  then 
held  by  the  assistant,  who  also  fixes  the  globe.     The  cutting 

*  '  Operative  Ophthalmology,'  p.  172. 


After-Complications  353 

is  done  with  a  Knapp's  needle,*  introduced  in  the  horizontal 
meridian  near  the  nasal  margin  of  the  cornea. 

Galezowskijt  in  cases  of  after-cataract  with  iritic  adhesions, 
has  employed  two  needles  with  sickle-shaped  blades,  one 
nearly  straight,  the  other  more  curved.  The  membrane  is 
perforated  twice  by  the  point  of  the  more  curved  instrument, 
first  on  the  near  side  from  before  backwards,  and  on  the  far 
side  of  the  pupil  from  behind  forwards.  The  two  needles  are 
introduced  through  the  cornea,  and  either  may  be  used  to 
support  the  membrane  while  the  other  cuts  with  sawing 
action.  Thus  the  cutting  may  be  done  from  in  front  by  the 
straight  needle  or  from  behind  by  the  curved  needle. 

Kugel  I  operates  upon  these  cases  with  an  ordinary  Graefe's 
knife,  introduced  at  the  outer  margin  of  the  cornea,  with  its 
edge  directed  down  or  up.  The  iris  is  supported  by  a  bent 
needle  passed  behind  the  iris  from  the  inner  corneal  margin. 
The  cutting  is  confined  as  far  as  possible  to  the  site  of  the 
former  pupil,  several  small  punctures  being  made,  leaving, 
perhaps,  only  isolated  threads  crossing  the  pupillary  area 
which  may  admit  of  extraction.  For  this  extraction  the 
corneal  opening  made  with  the  knife  is  enlarged  slightly  to 
admit  of  the  entry  of  forceps. 

In  the  practice  of  various  surgeons  the  remaining  pro- 
cedures receive  a  much  wider  application  than  is  absolutely 
essential.  Opinion  differs  chiefly  with  regard  to  after- 
cataracts  which  are  inelastic  and  somewhat  tough,  but 
which  still  admit  of  incision  with  cutting  needle  or  narrow 
knife.  Tearing  between  two  needles  is  evidently  used  as 
routine  procedure  for  ordinary  after-cataract  in  some 
places. §  And  Panas  practises  extraction  of  the  majority 
of  them. 

It  may  be  stated  broadly  that  in  tearing  the  membrane 
the  use  of  two  instruments  is  necessary,  the  one  to  counter- 
act the  pull  of  the  other,  and  to  prevent  the  pull  being 

*  Better  would  be  a  narrow  Graefe's  knife, 
t  ^^t--  d'Opht.,  October,  1896,  p.  587. 
X  A.f.A.,  lxiii(i9o6),  3. 
§  Elliot,  Ind.  Med.  Gazette,  xli  (1906),  165. 

23 


354  Cataract  Extraction 

transmitted  to  the  ciliary  body.  The  simplest  procedure 
is  the  Double  Needle  Operation.*  The  two  needles  can 
be  inserted  subconjunctivally  on  either  side  of  the  cornea 
to  penetrate  the  centre  of  the  capsule  at  the  one  opening, 
and  to  tear  the  membrane  from  the  centre  outwards  by 
separation  of  the  needles  in  various  directions.  It  has  an 
obvious  advantage  over  all  operations  which  require  definite 
incisions  for  the  insertion  of  instruments,  in  being  free 
from  the  risks  attending  possible  impaction  of  vitreous  in 
the  wound  and  loss  of  the  humour.  The  objection  to  the 
method  lies  in  a  tendency  to  ploughing  up  and  displace- 
ment of  vitreous.  It  is,  therefore,  a  distinctly  severer 
operation  than  simple  capsulotomy.  If  the  needles  be 
inserted  at  the  two  ends  of  a  corneal  meridian,  their 
points,  when  separated  in  the  capsular  opening,  swing 
directly  backwards  into  the  vitreous,  often  carrying  one  or 
other  leaf  of  capsule  back  also.  Their  points  of  insertion 
may  be  placed  at  some  distance  from  a  corneal  meridian, 
so  that  the  needles  converge  obliquely  to  the  capsular 
puncture  from  above.  The  separation  of  their  points  then 
does  not  plunge  them  deeply  into  the  vitreous.  The 
needles  remain  still  nearly  parallel  with  the  surfaces  of  iris 
and  capsule.  But  the  separation  is  apt  to  be  less  effective  in 
tearing,  in  that  it  does  not  admit  of  being  repeated  in 
such  varied  directions  as  when  the  sclero-corneal  punc- 
tures lie  in  a  corneal  meridian. 

The  method  is  suited  to  old  after-cataracts,  inelastic, 
and  somewhat  dense  from  capsular  degeneration  and  from 
the  development  of  fibrous  bands  and  membrane,  with  or 
without  posterior  synechiae.  Also  for  many  capsules  of 
overripe  cataracts,  including  Morgagnian  and  those  with  an 
anterior  plaque  which  is  not  very  dense,  at  least  at  its  centre. 

*  Bowman,  Medical  Times  and  Gazette,  October  30,  1852  ;  and 
Medic. -Chiriirg.  Transactions,  1853,  p.  315. 


After^CompIications  355 

Technique.— The  preliminaries  are  the  same  as  for 
division  with  the  narrow  knife.  The  speculum  is  inserted 
and  the  operator  stands  behind  the  patient's  head  with  a 
Bowman's  stop-needle  in  each  hand.  The  globe  is  fixed 
below  by  the  assistant.  If  the  membrane  appears  dense, 
the  needles  are  inserted  subconjunctivally  at  each  end  of 
the  horizontal  corneal  meridian,  or  near  it.  Each  needle 
is  directed  parallel  with  the  surface  of  the  iris  toward  the 


Fig.  87. — Bowman's  Stop-Nkedle  with  Cutting  Sides. 

middle  of  the  dilated  pupil.  The  one  at  the  nasal  side  of 
the  eye  is  inserted  first,  the  globe  being  rotated  outwards 
to  allow  of  this.  Either  needle  is  thrust  through  the 
thinnest  part  of  the  centre  of  the  capsule,  and  followed  by 
the  other  at  the  same  point,  or  quite  close  to  it.  Since 
the  angle  at  which  each  needle  meets  the  capsule  from  the 
limbus  puncture  is  very  acute,  the  point  naturally  does 
not  penetrate  the  membrane  so  easily  as  if  it  had  entered 


Fig.  88. — Discission  with  Two  Needles. 

nearer  the  centre  of  the  cornea.  One  needle  is  therefore 
used  to  fix  the  tissue,  while  the  opposing  point  is  thrust 
through.  If  any  difficulty  is  experienced  in  puncturing,  a 
small  central  tear  may  be  made  by  separating  the  points 
caught  in  the  tissue.  The  points  are  then  separated  widely 
by  bringing  the  handles  of  the  instruments  together  in 
front.  The  width  of  the  capsular  slit  thus  made  is  tested  by 
allowing  the  points  to  come  together  again.     Usually  they 

23—2 


35^  Cataract  Extraction 

need  separating  again  as  much  as  possible,  at  least  once, 
in  another  direction  to  secure  a  wide  opening.  The  leaves 
of  the  torn  capsule  are  kept  apart  more  by  the  forward 
projection  of  vitreous  than  by  the  tension  of  the  membrane. 
But  the  vitreous  must  not  be  unnecessarily  displaced. 

Only  where  the  membrane  is  fairly  thin,  as,  for  example, 
in  many  Morgagnian  cataracts,  may  the  limbus  punctures 
be  both  placed  above — the  one  up  and  in,  the  other  up 
and  out.  With  both  needles  directed  to  the  capsule  from 
above  neither  can  be  quite  so  useful  in  fixing  the  mem- 
brane to  resist  the  thrust  of  the  other  needle  as  when  they 
meet  from  directly  opposite  points.  There  is,  therefore, 
some  loss  in  efficiency  in  this  respect,  as  well  as  in  the 
tearing  apart  of  the  capsule,  to  make  up  for  the  gain  in 
safety  from  the  reduced  disturbance  of  vitreous. 

The  displacement  of  vitreous  in  this  operation  must  intro- 
duce a  slight  risk  of  exciting  increase  of  tension,  or  possibly 
detachment  of  retina  (see  Santos  Fernandes'  experience, 
already  mentioned).  Our  experience  of  the  method  in  Bombay 
was  small.  A  rise  of  tension  followed  in  two  of  our  cases. 
Curiously,  both  cases  were  in  children.  One  was  relieved  by 
leakage  of  aqueous  through  the  needle  punctures  on  manipula- 
tion of  the  eye. 

One  must  be  prepared,  also,  rather  frequently  to  find  the 
margins  of  the  opening  in  the  inelastic  membrane  approximat- 
ing more  or  less,  though  not,  in  my  experience,  so  much  as  to 
necessitate  extraction  of  the  capsule.  The  method  has  been 
practised  a  good  deal  in  England.  Bowman  punctured 
through  the  cornea  well  within  the  limbus.  Streatfield  used 
two  needle-hooks.  Knapp  has  used  two  of  his  needle-knives 
in  place  of  Bowman's  needles. 

Stilling*  has  operated  similarly  with  two  harpoon-needles, 
introduced  at  the  limbus.  If  it  were  desired  to  extract  the 
membrane,  these  needles,  introduced  through  small  incisions 
made  with  a  Graefe's  knife,  sufficed  to  draw  out  the  tissue. 

*  Centralbl.  f.  prakt.  Augeu.,  September,  1899,  S.  261. 


After^CompIications  357 

Pfliiger*  modified  the  needles  to  render  them  easy  of  with- 
drawal. 

Some  operators!  have  used  a  cystitome  introduced  through 
a  small  marginal  puncture  to  cut  or  tear  the  capsule. 

In  Agnew's  I  operation  both  cornea  and  capsule  are  pierced 
with  a  broad  needle  near  the  upper  margin  of  the  cornea. 
This  needle  is  retained  in  position  while  a  wound  is  made  at 
the  lower  corneal  margin,  and  through  this  a  small  sharp 
hook  introduced.  The  point  of  the  hook^  is  inserted  into  the 
capsular  opening  occupied  by  the  broad  needle,  and  traction 
put  upon  the  hook  to  tear  the  membrane.  The  broad 
needle  defends  the  ciliary  region  from  the  traction.  As  much 
tissue  is  drawn  out  of  the  wound  as  possible,  and  cut  off  by 
the  assistant  with  scissors. 

Noyes§  has  described  a  similar  operation  with  two  hooks 
pulling  against  one  another.  The  hooks  are  introduced 
through  limbus  puncture  and  counter-puncture,  and  through  a 
central  capsular  opening,  made  with  a  Graefe's  knife. 

Discission  with  Scissors. — This  is  applied  for  the  varying 
results  of  irido-cyclitis — i.e.,  where  the  after-cataract  is  fairly 
dense  and  more  or  less  attached  to,  or  united  with,  the  iris. 
The  operation  is  a  capsulotomy  or  irido-capsulotomy,  accord- 
ing to  the  degree  of  occlusion  of  pupil  and  of  coloboma,  and  in 
performance  is  almost  identical  with  de  Wecker's  iridotomy. 

The  eye  having  been  prepared  as  usual,  an  incision  is  made 
5  to  6  millimetres  long,  with  a  keratome,  at  the  limbus  or  a 
little  within  it.  Should  the  cataract  extraction  have  been  com- 
bined, and  should  the  pupil  be  not  much  displaced  upwards,  the 
incision  is  placed  above  in  front  of  the  old  cicatrix  to  allow  of 
vertical  section  of  the  membrane.  If,  however,  there  has  been 
no  coloboma  made,  as  after  simple  extraction  and  when  the 
condition  results  from  a  traumatic  cataract,  or  if  the  pupil  and 
coloboma  has  been  drawn  up||  to  the  line  of  the  old  wound, 
the  corneal  incision  may  be  made  at  the  outer  side  to  allow  of 
horizontal  division  of  the  membrane.     Sym's  blade  (Fig.  89) 

*  Ophth.  Klinik,  vi  (1902),  No.  13,  S.  193. 
+  Prouff,  Rev.  Clin.  cVOcul..,  novembre  3,  1884. 
X  Noyes,  Ophth.  Hosp.  Rep.,  vi  (1869),  p.  209.  §  Loc.  cit. 

II  The  vertical  traction  of  the  iris  may  then  be  expected  to  open  the 
slit  in  the  membrane. 


35^  Cataract  Extraction 

is  suitable  for  the  section.  The  fixation  of  the  globe  is  on 
the  opposite  side  of  the  cornea  to  that  selected  for  the  incision. 
The  knife  is  introduced  into  the  chamber  slowly  parallel  with 
the  iris.  It  is  then  nearly  withdrawn  to  allow  aqueous  to 
escape  and  the  diaphragm  to  come  forward,  and  the  point 
again  thrust  onward  to  pierce  the  capsule  and,  if  necessary, 
the  iris,  close  to  the  corneal  wound.  The  blade  being  then 
withdrawn,    de    Wecker's    scissors    are    introduced.       One 


Fig.  89.— Sym's  Knife  (Full  Size). 


blade  is  passed  in  front  and  the  other  behind  the  membrane 
through  the  small  puncture,  to  make  a  central  incision,  long 
or  short  according  to  the  apparent  needs  of  the  case,  as 
indicated  by  the  thickness  of  the  tissue  and  the  size  of  the 
pupil  and  coloboma,  and  the  appearance  of  the  iris. 

Should  a  single  incision  fail  to  gape,  a  second  is  made  at  an 
angle  to  outline  a  >  -  shaped  section.  The  tongue  of  tissue 
included  between  the  two  cuts  may  be   expected  to   shrink 


Fig.  90. — Broad  Irido-Capsulotomy  (Line  of  Incision  in 
Iris  and  Capsule). 

slowly  if  it  does  not  at  once  retract  sufficiently.  The  tongue 
of  tissue  may  be  made  broad  by  using  a  broader  keratome  and 
placing  the  two  diverging  cuts  at  each  end  of  the  (longer) 
incision  made  by  the  keratome  in  the  diaphragm  (Fig.  go) 
instead  of  from  its  middle. 

The  after-cataract  may  be  pierced  by  the  sharp  blade  of 
de  Wecker's  scissors,  if  preferred,  or  by  a  Graefe's  knife, 
instead  of  by  the  keratome  for  the  single  or  >  -shaped  section. 

Schweigger*   makes  a  smaller  incision,  and  uses   scissors 

*  A.f.  A.,  xxxvi  (1897),  S.  I. 


After 'Complications  359 

like  de   Wecker's,  but  reduced  in  size  to  lessen  the  risk   of 
vitreous  escape. 

The  main  objection  to  this  operation — viz.,  the  considerable 
risk  of  incarceration  and  loss  of  vitreous,  has  been  already 
mentioned.  The  danger  of  infection  from  this  cause,  however, 
might  be  diminished  or  removed  by  inserting  the  knife  sub- 
con  junctivally  through  sclera  and  cornea  instead  of  simply 
through  the  cornea.  This  should  increase  the  difficulty  of 
the  operation  but  slightly. 

Apart  from  accident  (infection  or  retinal  detachment,  due  to 
vitreous  prolapse),  and  from  insufficient  retraction  of  the 
membrane,  and  from  subsequent  closure  of  the  opening  by 
recurrent  inflammatory  changes,  the  visual  result  is  often  poor 
from  vitreous  opacities  and  other  changes  in  the  eye  due  to  the 
previous  iritis  or  irido-cyclitis. 

Strawbridge  "  designed  a  scissor-like  instrument,  with  fine- 
pointed  blades,  8  millimetres  long,  cutting  at  their  outer  edges. 
The  closed  instrument  was  used  to  pierce  the  after-cataract, 
and  the  opening  was  enlarged  by  separation  of  the  blades,  as 
in  discission  with  two  needles.  Blades  cutting  at  both  edges 
were  also  used. 

Lewinsohn  f  later  used  scissors  like  de  Wecker's,  but  with 
blades  rather  narrower  and  shorter,  and  cutting  at  their  outer 
edges.  These"  closed  blades  can  be  thrust  through  the  uncut 
cornea  like  a  needle.  There  is,  however,  little  advantage  in 
this — certainly  no  guarantee  against  the  entrance  of  vitreous 
into  the  puncture. 

Where  the  iris  is  atrophic,  and  therefore  devoid  of  resiliency, 
partial  Excision  of  the  matted  tissues — iris,  capsule,  and 
inflammatory  membrane — has  been  held  to  be  necessary.  This, 
however,  appears  doubtful,  for  slow  retraction  of  a  severed  flap 
or  tongue  of  the  diaphragm  should  take  place.  Even  the  pro- 
jecting angles  of  tissue  formed  by  a  T-shaped  division  com- 
monly retract  a  little,  in  spite  of  a  dense  substratum  of  new 
fibrous  membrane.  And  excision  operations  are  extremely 
likely  to  lead  to  considerable  loss  of  vitreous  in  eyes  quite 
unfit  to  bear  the  loss.  Hence  the  results  obtained  by  excision 
have  been  very  uncertain. 

*  Amer.  Journal  of  Med.  Science.,  1877,  p.  44Q. 
t  Centralbl.  f.  prakt.  Augen.,  Juli,  1899,  S.  207. 


360  Cataract  Extraction 

De  Wecker  designed  two  methods  (iritoectomie)  of  operating, 
shown  in  the  accompanying  figures.  In  the  first  method  an 
upper  corneal  incision,  6  to  8  millimetres  long,  made  with  a 
keratome,  is  followed  by  a  parallel  incision  through  the  dia- 
phragm, after  emptying  the  anterior  chamber  of  aqueous. 
Then  two  cuts  are  made  by  de  Wecker's  scissors,  as  in  irido- 
capsulotomy,  but  the  cuts  converge  instead  of  diverging. 
Thus  a  triangular  piece  of  membrane  is  isolated,  and  may  be 
withdrawn  by  the  scissors  or  by  iris  forceps.  Its  apex  should 
be  a  little  below  the  centre  of  the  cornea.  In  making  the 
second  of  these  cuts,  the  leaf  of  membrane  needs  to  be  drawn 
tight  with  forceps. 


Fig.  91.  Fig.  92. 

De  Wecker's  Iritoectomie,  Two  Methods. 
In  Fig.  91,  n,  b,  corneal  and  iris  incision  ;  f,  e,  d,  triangular  portion 

excised. 

Second  Method. — Where  the  pupil  and  coloboma  are  drawn 
up  to  the  scar  (above),  and  the  diaphragm  is  thick  and  dense, 
the  incision  through  cornea  and  diaphragm  is  made  below  by 
puncture  and  counter-puncture  with  a  narrow  Graefe's  knife. 
The  aqueous  is  allowed  to  leak  away  as  soon  as  the  corneal 
puncture  has  been  made.  There  may  be  considerable  difficulty 
experienced  in  dividing  the  tissues  with  the  scissors. 

Punches  have  been  designed  for  the  cutting  away  of  portions 
of  tough  membrane.  Stevenson*  described  an  improvement 
upon  an  instrument  devised  by  Kruger-Krjukow.  Vacher 
has  used  a  somewhat  similar  instrument. 

Knapp  describes  an  operation,  irido -cystectomy,  in  which  he 
draws  out  iris  and  pupillary  membrane  by  means  of  a  blunt 
hook,  after  section,  to  be  excised  by  scissors. 

Extraction. — There  is  only  one  form  of  after-cataract 
which  appears  almost  to  demand  this  treatment.     It  is 
*  Ophthalmology^  January,  1906. 


After^CompIications  361 

where  a  large  dense  anterior  plaque  has  for  some  reason 
been  left  behind.  But  in  Europe  such  capsules  must  be 
decidedly  rare.  And  when  met  with  they  are  likely  to 
escape  extraction  with  the  cataract  only  under  exceptional 
circumstances,*  especially  now  that  an  impulse  has  been 
given  to  intracapsular  extraction  by  Smith  of  Jullundur. 
Smaller  anterior  plaques  admit  of  ready  displacement 
sufficient  to  clear  the  pupil,  and  thin  ones  admit  of  being 
torn  by  two  needles.  Extraction  of  after-cataract,  at  one 
time  considerably  practised,  has  been  brought  somewhat 
into  favour  again  of  late  years  by  Panast  and  de  Wecker 
for  all  capsules  which  are  not  too  thin  to  permit  of  extrac- 
tion, and  not  broadly  adherent  to  iris  (a  few  fine  synechise 
are  of  no  consequence).  Panas  finds  that  the  conse- 
quences which  might  be  supposed  to  follow — cyclitis  from 
pull  on  the  ciliary  body,  vitreous  opacities,  glaucoma,  and 
detachment  of  the  retina — do  not  occur  even  so  frequently 
as  after  simple  discission  (!).  Apart  from  the  risk  of  pro- 
lapse and  loss  of  vitreous,  it  is  a  great  drawback  to  the 
treatment  that  it  cannot  follow  early  after  the  cataract 
extraction.  An  interval  of  three  to  six  months  must  be 
allowed  for  all  the  reaction  to  have  passed  off  and,  accord- 
ing to  Panas,  for  the  membrane  to  acquire  firmness.  Not 
many  patients  can  be  induced  to  return  for  a  second 
operation  after  so  long  an  interval. 

Technique. — The  pupil  must  be  dilated,  and  the  eye  prepared 
as  usual. 

An  incision  is  made  with  a  keratoma  above,  5  millimetres  or 
more  long  (8  to  lo  millimetres,  Panas),  either  i  to  i'5  millimetre 

*  I  have  had  to  leave  them  behind  at  the  time  of  the  cataract 
extraction  on  account  of  loss  of  control  by  the  patient  during  operation, 
and  in  other  cases  because  I  did  not  care  to  risk  prolapse  of  vitreous 
when  the  conjunctiva  was  unhealthy.  I  have  not  met  with  them  in 
eyes  with  vitreous  tension. 

t  Arch.  d'Opht.,  xxii  (1902),  149. 


362  Cataract  Extraction 

within  the  limbus,  or  subconjunctivally  just  behind  the  Hmbus 
(the  conjunctiva  being  pushed  downwards  by  the  knife  from  a 
point  I  "5  or  2  millimetres  above  the  cornea).  The  purely 
corneal  site  is  to  enable  the  operation  to  be  performed  without 
iridectomy  if  a  coloboma  has  not  already  been  made.  The 
more  peripheral  site  necessitates  a  coloboma,  either  dating 
from  the  primary  operation  or  made  at  this  time,  to  facilitate 
the  seizure  and  removal  of  the  membrane,  and  to  guard  against 
prolapse  or  incarceration  of  iris.     But  there  seems  little  doubt 


Fig.  93. — Panas'  Capsule  Forceps. 

it  should  always  be  chosen.  One  has  no  right  to  expose  the 
eye  to  the  risk  of  vitreous  being  left  uncovered  in  the  wound. 
A  small  iridectomy  may  be  useful,  also,  to  free  the  capsule 
from  one  or  more  small  iritic  adhesions. 

Suitable  capsule  forceps  must  be  selected,  or  an  attempt 
may  be  made  with  a  sharp  lens  hook.  There  is  no  difficulty 
in  seizing  a  dense  anterior  plaque  with  any  kind  of  capsule 
forceps.  But  if  the  whole  capsule  is  to  be  extracted,  an 
instrument  with  fairly  numerous  teeth  is  needed  to  give  a  firm 


Fig.  94.— Extraction  of  Capsule. 

hold  and  to  guard  against  slipping  of  the  forceps  and  against 
tearing  of  the  membrane. 

In  dealing  with  more  ordinary  after-cataracts,  Liebreich's 
and  de  Wecker's  forceps,  with  few  teeth,  have  been  used 
mainly  for  partial  extrafction,  the  central  portion  being  seized 
and  often  torn  away  as  in  operating  for  cataract  extraction. 
Panas'  forceps  afford  a  large  firm  hold.  One  blade,  pointed, 
is  thrust  through  the  capsule  and  passed  down  close  behind  it 
in  the  vitreous.  The  membrane  is  then  seized  between  this 
and  the  other  blade  in  front.     Slow  traction  with  slight  lateral 


After^Complications  363 

movements  is  used  to  free  the  opaque  capsule  gradually  from 
its  zonular  attachments.  An  impatient  pull  is  likely  to  tear 
the  membrane  and  to  bring  vitreous  forward  into  the 
wound. 

If  a  dense  after-cataract  resist  considerable  traction,  it  is 
recommended  to  alter  the  procedure  to  a  capsulotomy  with 
de  Wecker's  scissors,  especially  where  there  are  posterior 
synechiae,  lest  irido-dialysis  be  occasioned. 

Should  the  capsule  tear  and  the  opening  be  insufficient,  it  is 
recommended  to  enlarge  the  opening  by  de  Wecker's  scissors 
introduced  through  the  wound.  Should  the  capsule  be  adherent 
to  the  scar  of  the  cataract  operation,  it  is  cut  away  with  scissors 
close  to  the  wound. 

Cortex  imprisoned  between  the  two  layers  of  capsule  may 
be  set  free  into  the  anterior  chamber  by  the  manipulation  of 
the  forceps  It  may  be  removed  by  irrigation,  if  the  diaphragm 
in  front  of  the  vitreous  is  still  intact.  Otherwise  some  slight 
attempt  may  be  made  to  express  it. 

The  sharp  hook,  like  forceps  with  few  teeth,  is  apt  to  tear 
the  capsule  instead  of  pulling  it  away  from  the  zonule.  The 
point  is  passed  down  to  piece  the  lower  part  of  the  membrane 
at  a  comparatively  thin  spot.  Its  hold  may  perhaps  be 
strengthened  by  twisting  the  instrument  on  its  axis  in  an 
attempt  to  roll  up  the  capsule.  Should  the  capsule  tear  after 
being  considerably  loosened  and  displaced,  ordinary  iris  forceps 
may  serve  to  withdraw  it ;  otherwise  capsule  forceps  may  be 
needed. 

Tearing  of  the  membrane  may  interfere  with  anything 
approaching  complete  removal  of  it,  but  repeated  attempts  to 
seize  torn  capsule  embedded  in  vitreous  are  not  advisable  if  a 
fairly  central  incision  has  been  made. 

Complications. — There  may  be  prolapse  or  incarceration  of 
iris  if  iridectomy  is  not  done  at  the  time  or  at  the  primary 
operation.  Loss  of  vitreous  is  frequent.  It  is  practically 
certain  to  take  place  should  the  operation  be  undertaken  after 
an  unsuccessful  discission,  by  which  the  diaphragm  has  already 
been  perforated,  and  vitreous  brought  forward  into  the  anterior 
chamber. 


3^4  Cataract  Extraction 

DETACHMENT  OF  THE  RETINA. 

Loss  of  vision  from  this  complication  is  feared  especially 
after  large  escape  of  vitreous.  The  complication  has  also 
been  attributed  to  healing  of  the  vitreous  in  scars,  whether 
following  actual  loss  or  not.  It  is  then  due  to  the  forma- 
tion of  bands  in  the  vitreous,  connected  with  the  scar.  It 
has  also  been  ascribed  to  the  mere  displacement  and 
'  ploughing  up '  of  vitreous  in  some  discissions.  And  in 
highly  myopic  eyes  it  seems  that  some  of  the  retinal 
separations  which  have  followed  removal  of  the  lens,  if  due 
to  the  operation  at  all,  must  be  ascribed  to  the  uncompli- 
cated operation,  the  diaphragm  consisting  of  zonule  and 
posterior  lens  capsule  having  been  kept  intact.  In  highly 
myopic  eyes  it  appears  advisable  to  refrain  from  inter- 
ference with  posterior  capsule,  at  least  in  the  present  state 
of  our  knowledge  with  regard  to  the  complication.  The 
accident  may  happen  while  the  patient  is  in  hospital,  or 
only  after  a  considerable  interval.  Its  early  recognition 
may  be  difficult  owing  to  after-cataract,  and  possibly  owing 
to  vitreous  opacities.  Lately  I  observed  a  case  which 
underwent  spontaneous  cure. 

A  fortnight  after  a  Czermak's  subconjunctival  extraction  a 
prominent  grey  opaque  retinal  detachment  was  found  down- 
wards and  outwards.  The  vision  was  fingers  at  8  feet  with  a 
suitable  lens.  Ten  days  later  the  detachment  was  very  shallow 
and  folded,  and  the  retina  grey  only  in  the  ridges.  V  =  ^'jy. 
Shortly  afterwards  no  detachment  was  made  out. 

Complete  separation  of  the  retina  is  one  of  the  conse- 
quences of  protracted  irido-cyclitis,  but  in  itself  is  of 
little  consequence,  as  vision  is  otherwise  destroyed. 


CHAPTER  VI 
COMPLICATED  AND  SOFT  CATARACTS 

Cataract  with  glaucoma  —  Cataract  secondary  to  irido-cyclitis^ — 
Removal  of  the  transparent  lens  in  high  myopia  —  Dislocated 
lenses — The  extraction  of  soft  cataract — Suction. 

CATARACT  WITH  GLAUCOMA. 

The  shallow  anterior  chamber  commonly  seen  with  the 
swollen  liquefying  form  of  cataract  has  been  repeatedly 
referred  to  in  the  foregoing  pages.  As  might  be  anticipated, 
this  shallowing  sometimes  causes,  or  assists  in  causing, 
glaucoma. 

In  Bombay  the  triple  association  is  fairly  frequently 
seen  of  recent  congestive  glaucoma  with  swollen  cataract 
and  very  shallow  anterior  chamber.  And  the  connexion  is 
emphasized  by  the  following  considerations:  (i)  These 
cases  include,  perhaps,  the  majority  of  the  subacute 
glaucomas  seen  there,  the  great  bulk  of  primary  glaucoma 
in  India  being  distinctly  chronic,  simple,  or  congestive. 
(2)  Other  forms  of  cataract  associated  with  recent  attacks 
of  congestive  glaucoma  are  decidedly  uncommon.  (3)  The 
shallowing  of  the  anterior  chamber  is  frequently  extreme. 
Where  comparison  can  be  made  with  the  chamber  of  a 
fellow  eye  as  yet  uninfluenced  by  glaucoma,  by  cataract, 
or  by  cataract  extraction,  that  of  the  glaucomatous  eye  is 
generally  distinctly  the  shallower  of  the  two.     In  a  few 

365 


o 


66  Cataract  Extraction 


cases  the  difference  in  depth  is  inappreciable  ;*  but  it  must 
be  borne  in  mind  that  the  dilated  pupil  and  altered  iris  of 
the  affected  eye  prevent  very  exact  comparison  between 
the  two  eyes.  This  difference  in  anterior  chambers,  though 
not  quite  exclusively  the  property  of  these  cataractous 
glaucomas,  is  sufficiently  so  to  remain  their  chief  dis- 
tinctive feature.  During  the  period  of  collection  of  the 
statistics  given  below  it  was  found  but  five  times  in 
glaucomatous  eyes  without  cataract,  or  with  only  incipient 
cataract.  In  ordinary  congestive,  subacute  or  chronic f 
glaucoma  the  relation  is  commonly  reversed;  the  chamber 
of  the  affected  eye  is  shallow,  but  less  so  than  that  of  the 
unaffected,  but  predisposed  eye.  (See  Czermak,  quoted  in 
the  Ophthalmic  Review,  xvi  [1897],  199). 

It  is  by  no  means  contended  that  the  cataract  formation 
always  takes  a  very  large  place  in  the  etiology  of  these  high 
tensions.  For  the  large  majority  of  such  swollen  cataracts 
pass  through  their  whole  course  without  altering  the  tension 
of  the  eye  at  all.  And  of  the  thirty-three  of  these  cataracts 
associated  with  recent  congestive  glaucoma,  of  which  I  have 
notes,!:  five  had  advanced  to  the  Morgagnian  stage,  though  in 
four  out  of  these  five  cases  the  glaucoma  was  by  no  means 
advanced.  In  two  of  them  there  was  still  some  pupillary 
reaction  obtainable  ;  in  one  of  these  two  and  in  another  case 
the  tension  gave  way  completely  to  eserin  before  operation ; 
and  in  the  fourth  case  the  attacks  of  high  tension  had  been 
intermittent. 

Among  other  factors  in  etiology  may  be  noted  the  predis- 
position to  glaucoma  frequently  shown  by  the  (less)  shallow 
chamber  of  the  unaffected  fellow  eye.     And  at  times  there  is 

*  I  have  very  rarely  seen  congestive  glaucoma  together  with  Mor- 
gagnian cataract  and  an  anterior  chamber  deeper  than  that  of  the 
unaffected  eye  ;  but  in  only  one  case  was  the  glaucoma  apparently  of 
recent  origin.  In  this  case  it  must  be  assumed  that  the  cataract 
played  no  part  in  the  production  of  the  high  tension. 

t  I  cannot  speak  from  experience  with  regard  to  acute  glaucoma, 
having  had  but  a  small  acquaintance  with  it. 

%  Collected  some  years  ago. 


Complicated  and  Soft  Cataracts  367 

a  definite  exciting  cause  for  the  onset  of  high  tension  ;  in  two 
of  our  cases  it  was  operation  upon  the  other  eye,  and  in  at 
least  one  other  case  it  was  probably  the  use  of  a  mydriatic. 

During  the  two  and  a  half  years  over  which  the  above 
thirty-three  cases  have  been  spread,  six  similar  cataracts  were 
seen  with  only  a  low  degree  of  phis  tension,  in  eyes  quite  or 
nearly  free  from  injection.  And  ten  others  were  found  without 
high  tension,  but  with  some  enlargement  and  sluggishness  of 
pupil.  In  six  of  these  cases  the  abnormality  of  pupil  was  very 
slight,  and  might  easily  have  escaped  notice.  In  two  of  the 
remaining  three,  there  was  contraction  of  the  field  of  projec- 
tion also,  evidently  from  high  tension  that  had  passed  off"  for 
the  time. 

Thus  the  prima  facie  presumption  in  favour  of  this 
etiological  relationship  between  swollen  cataract  and 
glaucoma  is  supported  by  a  considerable  body  of  evidence. 
It  is  in  our  experience  further  borne  out  in  treatment.  In 
two  of  our  first  few  cases  treatment  of  the  glaucoma  was 
attempted  on  orthodox  lines,  but  both  cases  gave  a  lot  of 
trouble. 

In  one  case  the  anterior  chamber  failed  entirely  to  refill 
after  a  perfect  iridectomy  with  conjunctival  flap.  Plus  tension 
returning  after  three  weeks  necessitated  cataract  extraction, 
assisted  by  preliminary  posterior  scleral  puncture.  The 
incision  had  to  be  made  mostly  with  scissors,  owing  to  the 
absence  of  an  anterior  chamber.  Some  cortex  was  left  obscur- 
ing vision  ;  and  three  weeks  later  still,  plus  tension  was  again 
evident.  After  another  posterior  scleral  puncture  the  patient 
disappeared,  tired  of  treatment. 

In  the  other  case  the  tension  was  finally  reduced,  and  useful 
sight  restored  by  a  '  sclerotomy  with  conjunctival  infolding,' 
after  the  failure  successively  of  (i)  eserin  with  small  sclero- 
tomies, (2)  iridectomy,  (3)  cataract  extraction,  and  (4)  sclero- 
tomy with  division  of  adherent  root  of  iris. 

In  the  light  of  these  cases  it  was  then  recognized  that  if 
the  cataract  were  admitted  as  a  factor  in  the  production  of 
the  glaucoma,  the  correct  treatment  of  the  latter  neces- 


368  Cataract  Extraction 

sitated  the  prompt  removal  of  the  lens.  This  was  done 
with  combined  iridectomy  in  a  considerable  number  of 
cases,  with  very  satisfactory  results  upon  the  whole.  Where 
possible,  the  tension  was  reduced  by  eserin  beforehand. 
But  in  the  majority  of  cases  the  tension  was  still  high  at 
the  time  of  the  cataract  extraction.  It  was  considered  that 
the  danger  of  intraocular  haemorrhage  was  probably  slight 
in  these  eyes,  owing  to  the  glaucoma  being  usually  of  quite 
recent  origin,  and  being,  partly  at  least,  secondary.  It  was 
thought  that  the  changes  in  the  blood-vessels  were  prob- 
ably not  marked.  We  have,  however,  met  with  two  cases 
of  expulsive  haemorrhage  in  such  eyes,  and  we  had 
another  unsatisfactory  result  from  large  prolapse  of  iris 
and  of  vitreous  (without  loss).  Hence  latterly  we  have 
always  reduced  the  tension  before  removing  the  lens.  In 
some  cases  eserin  has  sufficed  for  this.  In  other  cases  I 
obtained  a  lasting  reduction  in  tension  by  a  form  of  sub- 
conjunctival paracentesis.  Thus  I  have  been  able  to  wait 
for  two  or  three  weeks,  if  necessary,  for  the  congestion  of 
the  eyes  to  subside  mainly  or  entirely  before  operating 
upon  the  lens.  I  have  preferred  this  to  preliminary  iridec- 
tomy because  of  our  unfortunate  early  experience  of 
iridectomy  in  these  cases,  above  mentioned.  One  feels 
that  should  the  anterior  chamber  remain  empty  in  these 
congested  eyes,  there  is  every  opportunity  for  consolidation 
of  adhesion  between  the  base  of  the  iris  and  the  periphery 
of  the  cornea,  closing  the  filtration  angle  permanently,  and 
ensuring  the  return  of  plus  tension.  By  the  paracentesis 
which  I  have  performed  the  tension  has  been  reduced 
though  the  anterior  chamber  has  not  remained  empty. 
Hence  its  superiority  here  over  iridectomy.  A  small  tongue 
or  flap  of  cornea  and  sclerotic  is  isolated,  with  its  base  at 
the  corneal  margin,  thus.  Selecting  a  site  preferably 
upwards   and   outwards,  a   very    narrow    Graefe's    knife. 


Complicated  and  Soft  Cataracts  369 

slightly  less  than  i, millimetre  in  width,  is  inserted  through 
the  sclerotic  at  a  distance  of  about  i"5  millimetres  from 
the  corneal  margin,  into  the  angle  of  the  anterior  chamber. 
1  he  puncture  is  made  subconjunctivally  by  sliding  the 
conjunctiva.  The  blade  is  introduced  parallel  to  the  iris, 
and  a  small  incision  made  i"5  to  2  millimetres  long.  Then 
at  each  end  of  this  small  section  the  edge  of  the  knife  is 
turned  forwards,  and  with  slow  sawing  movements  a  small 
subsidiary  incision  made  as  far  as  the  corneal  circum- 
ference. The  whole  is  subconjunctival,  as  the  conjunctiva 
is  raised  by  escaping  aqueous.  The  sawing  movements 
with  the  back  of  the  blade  pressing  on  the  iris,  the  anterior 
chamber  being  empty,  may  be  painful.  For  this  reason, 
and  also  to  avoid  unnecessary  haemorrhage,  adrenalin  is 


Fig.  95.— Modified  Paracentesis. 

instilled  beforehand  with  the  cocain,  and  the  cutting  is 
done  mostly  or  entirely  in  the  withdrawal  movements  of 
the  knife.  It  is  uncertain  yet  how  long  these  small 
incisions  drain.  Some  at  least  appear  to  leak  permanently. 
It  is  necessary  to  keep  the  pupil  under  the  influence  of 
eserin  afterwards,  to  prevent  adhesion  of  the  iris  to  the 
wound. 

A  causal  relationship  between  cataract  and  glaucoma 
exactly  the  reverse  of  the  above  is  frequently  seen.  In 
India  cataract,  as  a  result  of  primary  glaucoma,  frequently 
comes  on  sufficiently  early  to  reduce  what  would  be  other- 
wise useful  vision.  It  is  not,  however,  sufficiently  ripe 
to  permit  of  extraction  at  the  time  when  operation  is 
demanded  for  the  high  tension.     It  may  be  expected  to 

24 


Z7^  Cataract  Extraction 

go   on    developing   slowly  after  the  glaucoma   has    been 
relieved,  and  may  need  extraction  months  or  years  later. 

The  chance  coincidence  of  cataract  and  early  glaucoma 
in  the  same  eye  is  seen  at  times.  The  absence  of  etio- 
logical relation  between  the  two  may  be  assumed  with  the 
forms  of  cataract  that  lead  to  no  shallowing  of  the  anterior 
chamber.  Incipient  cataract  and  incipent  glaucoma  are 
seldom  seen  together,  probably  because  most  lenses  in  the 
early  stage  of  cataract  formation  are  reduced  in  volume.  I 
have  notes  of  a  few  cases  of  glaucoma  developing  together 
with  hypersclerosis  of  the  lens  ;  these  lenses  are  probably 
not  smaller  than  normal.  Supposing  operation  for  the 
reduction  of  tension  has  failed,  one  may  feel  tempted  to 
extract  an  unripe  cataract  to  get  rid  both  of  the  tension  and 
opacity.  The  only  two  cases  in  which  I  operated  thus 
turned  out  badly. 

CATARACTS  SECONDARY  TO  IRIDO-CYCLITIS, 

with  occlusion  of  pupil,  and  often  with  total  posterior 
synechia  {cataracta  accreta),  may  give  good  results  if  the 
eye  be  not  softened  and  if  the  projection  of  light  be  fair. 
The  cataract  may  not  be  detected  until  an  artificial  pupil 
has  been  made,  and  after  the  lens  extraction  there  may 
possibly  be  a  third  operation  required  for  membranous 
opacity.  This  is  rather  tedious.  If  it  seems  very  probable 
that  cataract  is  present — e.g.,  in  old  dense  occlusion,*  or  if 
the  lens  can  be  partly  seen  through  thin  pupillary  mem- 

*  It  is,  as  a  rule,  scarcely  too  much  to  assume  that  in  old  dense 
occlusion  of  pupil  a  fairly  ripe  cataract  is  present,  and  that  it  is  fit  for 
extraction  if  the  tension  of  the  eye  be  fair  and  the  projection  of  light 
good.  But  in  one  patient,  aged  thirty-two  years,  acting  on  this 
assumption,  I  made  a  large  incision  unnecessarily,  and  lost  some 
vitreous.  The  lens  had  become  absorbed.  A  simple  free  incision  of 
the  remains  of  iris,  capsule,  and  inflammatory  tissue  would  have  been 
sufficient. 


Complicated  and  Soft  Cataracts  371 

brane — the  operation  for  extraction  may  be  combined  with 
an  iridectomy  upwards.  And  in  some  cases  opaque  capsule 
may  be  removed  at  the  same  time.  It  is  surprising  how 
readily  the  capsule  comes  away  from  its  old  adhesions  to 
iris,*  whose  tissue  may  now  be  more  or  less  atrophied  and 
friable.  Proceeding  thus  in  the  one  operation,  but  step  by 
step,  I  have  had  unexpectedly  good  results.  The  number 
of  cases  has,  however,  been  very  small. 

In  Wenzel's  Methodt  the  knife,  while  making  the 
corneal  incision,  passes  through  iris  and  often  through  the 
ns  capsule,  a  portion  of  these  matted  membranes  being 
afterwards  cut  away  with  de  Wecker's  scissors.  This 
mode  of  operating  may  be  almost  forced  on  one  by  a 
very  shallow  chamber,  and  is  perhaps  preferable  when 
there  is  much  matting  together  of  iris  and  lens  capsule. 

I  have  only  operated  thus  in  three  glaucomatous  eyes, 
where  there  was  no  occlusion  of  pupil  nor  any  past  iritis, 
but  merely  very  shallow  chamber.  Unless  the  chamber  is 
very  shallow,  aqueous  must  be  allowed  to  escape  as  soon 
as  the  puncture  has  been  made,  to  bring  the  lens  and  iris 
forward.  Unless  the  chamber  be  nearly  emptied,  the 
capsule  of  the  lens  may  escape  division  in  the  making  of 
the  section.  The  equator  of  the  lens  must  then  be  forced 
forward  to  the  wound  by  pressure  on  the  cornea  below,  for 
incision  of  the  capsule  along  the  whole  length  of  the  wound 
by  the  cataract  knife.  Where  there  is  a  firm  diaphragm 
made  up  of  iris,  lens  capsule,  and  inflammatory  membrane 
the  blades  of  de  Wecker's  scissors  may  have  to  be  intro- 
duced into  the  eye  after  the  expulsion  of  the  lens,  to  excise 
a  portion  of  the  combined  membrane.     Two  converging 

*  However,  in  one  case  I  tore  iris  away  from  its  base  below.  The 
coloboma  made  above  became  closed,  but  the  patient  counted  fingers 
at  8  feet  with  lens  through  the  gap  below. 

t  'Manuel  d'Oculistique,'  i  (Paris,  1808),  120. 

24 — 2 


372  Cataract  Extraction 

cuts  are  made,  one  scissor-blade  being  passed  in  front  of 
the  membrane  and  the  other  behind  it. 


REMOVAL   OF    THE    TRANSPARENT    LENS    IN 
HIGH  MYOPIA. 

The  scope  of  this  volume  does  not  include  the  con- 
sideration of  the  operative  treatment  of  high  myopia.  The 
treatment  here  claims  our  interest  merely  with  regard  to 
the  various  methods  of  extraction  practicable  alike  for 
transparent  lenses,  and  for  lamellar  and  other  partial 
stationary  cataracts — their  relative  advantages  and  risks, 
and  their  bearing  upon  cataract  work  generally.  The 
patients  being  mostly  young,  linear  extraction  is  commonly 
applicable.  And  this  is  usually  preceded  by  discission,  to 
soften  and  to  loosen  the  lens  substance,  and  followed  by 
discission  for  after-cataract. 

Though  opacification  and  loosening  of  the  posterior 
layers  may  often  be  obtained  by  slow  cataract  formation 
from  very  limited  discission,  repeated  once  or  twice  if 
necessary,  yet  owing  to  the  tediousness  of  the  process  and 
to  the  difficulty  experienced  in  regulating  it  so  as  to  avoid 
the  complications,  plus  tension  and  irritation  of  the  iris, 
many  surgeons  find  it  preferable  to  secure  rapid  breaking 
up  of  the  lens  by  very  free  needling.  The  complications 
are  prevented  or  forestalled  by  the  use  of  iced  applications 
and  rest  in  bed,  and  by  early  extraction.  Others  advocate 
primary  linear  extraction,  with  later  discission  of  after- 
cataract  (Weber,  Hess,  Sattler)  ;  others  primary  flap 
extraction  (Vacher,  Fukala,  Hirschberg). 

High  tension  from  swelling  of  the  lens  is  not  in  itself  a 
very  serious  matter.  It  causes  trouble,  however,  by  neces- 
sitating extraction  of  the  lens — necessarily  very  incomplete 
— before  the  ripening  process  is  sufficiently  advanced,  and 


Complicated  and  Soft  Cataracts  373 

while  the  eye  is  painful  and  irritable.  General  anaesthesia 
may  be  required  on  this  account,  and  afterwards  the  con- 
gested iris  may  not  respond  to  the  instillation  of  atropin. 

For  the  wide  opening  of  the  capsule  at  the  preliminary 
discission,  either  a  single  long  cut  or  a  crucial  division  is  made. 
And  the  lens  is  rather  deeply  incised.  Some  operators  use  a 
Graefe's  knife  for  this.  Emmert*  breaks  up  even  the  nucleus 
and  the  posterior  layers  of  the  lens  with  a  very  broad  discission- 
needle.  It  is  considered  wise  to  avoid  allowing  the  aqueous 
to  escape,  lest  the  pupil  should  thereby  contract,  and  the  iris 
form  adhesions  to  the  torn  capsule.  Mooren,  however,  com- 
bined massage  of  the  lens  with  discission. 

At  the  linear  extraction  the  capsular  opening  is  still  further 
enlarged  if  not  already  very  wide. 

For  primary  extraction  of  the  transparent  lens  Sattlerf 
makes  an  incision  6  to  8  millimetres  long,  i"5  to  2  millimetres 
within  the  upper  corneal  margin,  with  Weber's  curved  kera- 
tome  (p.  26).  He  introduces  a  sharp  iris  hook,  and  makes  first 
a  horizontal  slit  in  the  capsule  behind  the  lower  margin  of  the 
widely  dilated  pupil,  and  from  that  tears  freely  the  whole  of 
the  anterior  capsule.  Then,  with  the  back  of  the  hook,  he 
loosens  the  lens  substance  from  the  equatorial  and  posterior 
portions  of  capsule,  and  proceeds  to  evacuate  the  lens  by 
depression  of  the  peripheral  lip  of  the  wound  with  a  Daviel's 
curette,  together  with  external  spoon  pressure  about  the  lower 
corneal  margin.  The  nuclear  portions  of  lens  matter  are  first 
expressed.  Two-thirds  or  three-fourths  of  the  lens  matter  are 
thus  removed,  and  atropin  is  instilled.  The  remainder  left 
behind  is  insufficient  to  give  rise  to  high  tension  by  swelHng.  If 
the  iris  enters  the  wound  during  the  operation  it  is  replaced. 
Discission  of  the  posterior  capsule  and  lens  debris,  practised 
after  a  week  or  so,  "  is  sufficient  to  obtain  a  clear  pupil  in  a 
fortnight  or  little  more."  He  considers  that  preliminary  dis- 
cission should  be  given  up  entirely. 

Axenfeld  I  and  Gelpke  §  remove  the  anterior  capsule  with 

*  /i./^.,  Iv(i903),  2,  358. 

t  Ber.  der  xxv'u  Vers,  der  ophth.  Ges.  zu  Heidelberg.,  1899,  S.  207. 

+  Kl.  Mbl.f.  A.,  xli  (1903),  I,  60. 

§  A.f.  A.,  xlix  (1904),  2,  152. 


374  Cataract  Extraction 

forceps  to  obtain  the  widest  possible  opening,  and  so  to  reduce 
the  need  for  treatment  of  after- cataract.  Emmert  extracts 
the  lens  twenty-four  hours  after  the  free  needling  which  he 
practises.  Though  after  this  early  extraction  often  a  con- 
siderable time  is  taken  up  in  the  absorption  of  lens  remnants, 
he  has  found  discission  for  after-cataract  nearly  always 
unnecessary.  The  avoidance  of  any  interference  with  the 
posterior  capsule  is  a  matter  of  importance  in  these  highly 
myopic  eyes,  having  regard  to  the  danger  of  causing  detach- 
ment of  the  retina  by  displacement  of  vitreous.  And  the  risk 
of  post-operative  glaucoma  is  thus  reduced  also. 

In  order  to  lessen  existing  astigmatism,  the  incision  has  been 
sometimes  placed  at  right  angles  to  the  meridian  of  greatest 
corneal  curvature. 

Rogman*  prefers  suction  to  ordinary  linear  extraction. 

Primary  linear  extraction  necessitates  a  larger  section 
than  suffices  for  evacuation  of  lens  substance  after  free  dis- 
cission ;  hence  possibly  a  slightly  greater  risk  of  infection 
and  of  prolapse  or  incarceration  of  iris. 

Should  there  be  adhesions  of  vitreous  or  capsule  to  the 
corneal  scar  after  linear  extraction,  Sennf  divides  the  ad- 
herent tissue,  lest  the  pull  upon  the  vitreous  should  lead  to 
detachment  of  the  retina.  Sattler  had  vitreous  loss  in  20  per 
cent.,  Schweigger  in  10  per  cent.,  and  Pfliiger  in  10  per  cent, 
of  their  extractions.  Detachment  of  retina  occurred  in  4-34 
per  cent,  of  Sattler's  cases,  in  14  per  cent,  of  Schweigger's, 
and  in  only  i  per  cent,  of  Pfliiger's.  The  latter  operator 
practised  discission  of  after-cataract  in  more  than  half  of  his 
cases.  Thus  his  experience  is  that  this  discission  does  not  lead 
to  retinal  detachment. 

In  patients  over  thirty-five  years  of  age  primary  flap  extrac- 
tion of  the  transparent  lens  is  commonly  preferred,  followed, 
if  necessary,  by  discission.  Linear  extraction  after  pre- 
liminary needling  is,  however,  practised  by  some  operators  in 
older  patients,  since  often  in  these  highly  myopic  eyes  there  is 
not  a-  large,  hard  nucleus.  But  one  cannot  be  sure  of  the 
condition  of  the  nucleus  beforehand,  and  in  these  older  patients 

*  Ann.  d'Ocitl.,  cxxi  (1899),  i.  f  A./.  A.,  xliii  (1901),  241. 


Complicated  and  Soft  Cataracts  375 

the  needling  frequently  causes  reaction.  To  lessen  the  risk  of 
exciting  high  tension,  the  discission  has  been  sometimes  com- 
bined with  an  iridectomy. 


DISLOCATED  LENSES. 
A.  In  the  Anterior  Chamber. 

Replacement  of  the  lens  through  the  pupil  has  been 
practised  occasionally.  It  seems  applicable  only  to  lenses 
spontaneously  dislocated,  which  are  often  shrunken,  and 
have  lain  formerly  subluxated  behind  the  iris  without 
causing  irritative  symptoms,  and  may  still  retain  their 
connexion  with  stretched  zonule. 

The  most  suitable  and  safest  extraction  is  by  Czermak's 
lower  subconjunctival  method.  The  lens  occupying  the 
lower  portion  of  the  chamber  is  then  quite  close  to  the 
section,  which  can  be  made  with  scissors  without  dis- 
placing the  lens.  And  there  is  little  risk  of  loss  of  vitreous. 
This  risk  constitutes  the  chief  danger  and  difficulty  with 
other  incisions.  Should  the  lens  have  lain  long  in  its 
abnormal  position,  however,  it  may  have  become  fixed  to 
the  cornea,  rendering  a  lower  section  difficult  and  only  to 
be  accomplished  by  transfixion  or  displacement  of  the  lens. 
In  India  a  considerable  proportion  of  the  patients  came 
for  treatment  only  when  sight  had  been  lost  by  secondary 
glaucoma  caused  by  the  luxated  lens.  Operation  was 
rnerely  for  the  relief  of  pain.  In  these  eyes  loss  of  vitreous 
mattered  little,  and  the  ordinary  upper  section  sufficed. 

In  making  the  ordinary  section  vitreous  may  begin  to 
escape  even  before  the  incision  is  completed,  especially  if 
there  be  high  tension.  Desmarres'  retractor  should  be 
used  for  the  upper  lid,  and  finger  depression  for  the  lower 
lid,  instead  of  the  stop-speculum.  The  upper  portion  of 
the  lens  may  lie  in  the  path  ordinarily  taken  by  the  knife 


37^  Cataract  Extraction 

in  making  the  section,  or  possibly  the  upper  part  of  the 
iris  may  be  pressed  forward  against  the  cornea  by  vitreous 
tension.  In  an  eye  in  which  the  attainment  of  useful 
vision  is  still  possible,  it  is  important  not  to  risk  displace- 
ment of  the  lens  backwards  by  transfixion  with  the  knife. 
There  is  always  room  for  an  incision  of  moderate  extent, 
made  in  the  usual  way  with  a  very  narrow  Graefe's  knife, 
I  millimetre  or  less;  and  this  may  be  enlarged,  if  necessar}-, 
with  scissors.  If  the  upper  part  of  the  anterior  charnber 
be  extremely  shallow,  the  iris  must  be  cut  with  the  knife,  or 
the  section  might  be  begun  by  sawing  from  in  front,  as  was 
done  by  Spencer  Watson,*  in  187 1,  with  a  scalpel.  Some 
operators  have  preferred  linear  extraction  by  outer  section, 
the  point  of  the  keratome  being  thrust  behind  the  lens. 
And  Miiller  recommends  his  operation  (p.  201)  for  dis- 
located lenses.    The  lens  is  removed  with  a  loop  or  spoon. 

The  instillation  of  eserin  beforehand  is  indicated  t  in 
order  that  the  lens  may  be  supported  by  the  iris  and 
prevented  from  slipping  backwards  through  the  pupil. 
There  is  then  no  need  for  the  very  inconvenient  fixation 
of  the  lens  by  transfixion  with  a  needle,  or  for  operation 
with  the  patient  in  the  semi-prone  position — methods 
which  have  been  adopted. 

The  instillation  of  adrenalin  before  or  with  the  cocain  is 
advisable  in  all  cases,  and  especially  necessary  in  painful 
eyes,  to  ensure  quietness  I  so  far  as  possible. 

*  The  Practitioner^  1 871,  p.  271. 

+  According  to  Eversbusch  {Vers,  der  ophth.  Ges.  su  Heidelberg^ 
1878),  eserin  instillation  is  inadmissible  before  operation  for  a  con- 
genitally  ectopic  lens,  still  attached  to  an  elongated  zonule.  The  pull 
on  the  zonule  caused  by  myosis  may  draw  the  shrunken  lens  back  into 
the  posterior  chamber. 

X  In  one  of  our  operations  upon  a  dislocated  lens  adherent  to  the 
cornea — a  shrunken  lens  which  evidently  had  been  Morgagnian,  but 
from  which  all  the  fluid  had  been  absorbed — its  detachment  from  the 
cornea  with  the  spoon  caused  pain  sufficient  to  excite  spasm  of  orbi- 


Complicated  and  Soft  Cataracts  I'i'j 

B,  In  the  Vitreous. 

I  have  no  experience  of  extraction  of  lenses  dislocated  into 
the  vitreous.  It  would  be  undertaken  only  if  sight  were  being 
lost  through  high  tension  or  other  complication  due  to  the 
displaced  lens.  Smith  of  Jullundur  has  removed  many  dis- 
located lenses  with  a  spoon  or  by  simple  expression,  but  gives 
no  details.  Possibly  in  his  cases  the  lenses  had  resumed  their 
normal  position. 

Should  the  lens  lie  quite  free  in  the  vitreous,  it  may  be 
possible  to  bring  it  into  the  anterior  chamber  merely  by 
dilating  the  pupil  and  placing  the  patient  in  the  prone  position. 
Euphthalmin  and  cocain  are  recommended  as  mydriatics. 
Should  this  succeed,  the  prone  position  is  maintained  while 
myosis  is  obtained  by  eserin,  and  the  lens  is  then  extracted. 

Often  the  lens  retains  some  connexion  with  the  ciliary  body 
either  by  means  of  zonule  or  by  bands  of  new  tissue.  It  may 
then  lie  quite  close  to  the  iris.  Knapp*  has  succeeded  in 
delivering  such  lenses,  with  little  or  no  loss  of  vitreous,  mainly 
by  external  pressure — finger  pressure  applied  below  through 
the  lower  lid.  A  speculum  is  used  only  for  the  making  of  the 
section.  This  is  upwards,  the  summit  of  the  flap  being  placed 
2  millimetres  within  the  corneal  margin.  The  final  delivery 
is  aided  by  the  introduction  of  a  spoon  by  the  assistant. 

Von  Graefe  and  von  Arlt  have  succeeded  in  piercing  more 
deeply  placed  lenses  with  a  needle  through  the  sclerotic,  and 
so  bringing  them  up  into  the  pupil  or  into  the  anterior  chamber 
for  removal  with  a  spoon  or  loop.  Agnew's  '  bident  't  has 
been  used  similarly  for  bringing  lenses  up  for  extraction — 
lenses  which  are  too  freely  movable  to  be  readily  pierced  by 
a  needle.  The  bident  consists  simply  of  two  straight  needles 
fixed  in  a  holder  parallel  to  one  another,  ^  inch  apart.  The 
two  needles  are  passed  into  the  vitreous  behind  the  lens,  and 
are  swung  forward  supporting  the  lens. 

cularis.  Thus  there  was  a  considerable  loss  of  vitreous.  Cocain  alone 
had  been  instilled.  If  it  had  been  combined  with  adrenalin,  possibly 
the  accident  might  not  have  happened.  The  visual  result  of  the 
operation,  however,  was  good — at  least,  while  the  patient  was  under 
observation. 

*  A.f.  A.,  xxii  (1890),  171. 

t    Trans.  Amer.  Oph.  Soc,  1885,  p.  69. 


37^  Cataract  Extraction 

C.  Subluxated  Lenses. 

1.  In  the  Pupil. — Spontaneously  displaced  lenses  in  this 
situation  are  more  or  less  shrunken  lenses,  either  ectopic  or 
merely  the  nuclear  remains  of  Morgagnian  cataracts,  lying  in 
collapsed  capsule.  In  the  case  of  the  larger  lenses,  and  there- 
fore particularly  in  traumatic  displacement,  treatment  may  be 
demanded  for  the  relief  of  secondary  glaucoma. 

Possibly  by  the  use  of  a  weak  mydriatic  and  forward  bend- 
ing of  the  head,  further  displacement  of  a  shrunken  lens  into 
the  anterior  chamber  may  be  secured.  And  after  sufficient 
eserin  instillation  to  fix  the  lens  there,  it  may  be  extracted. 
Otherwise  operation  must  be  undertaken  with  the  lens  still 
lying  in  the  pupil.  Czermak's  subconjunctival,  also  L.  Miiller's 
and  Bourgeois'  sections,  have  each  been  recommended.  It  is 
suggested,  also,  to  place  the  section  at  that  portion  of  the 
corneal  margin  towards  which  the  lens  margin  points,  in  order 
that  a  spoon  or  loop  may  the  more  readily  be  introduced 
behind  the  lens.  If  the  small  lens  lies  loosely  in  the  pupil,  it 
may  be  fixed  by  a  needle  passed  in  through  the  sclerotic. 

2.  In  the  Posterior  Chamber. — Here,  again,  there  may  be  high 
tension,  or  operation  may  be  advisable  on  account  of  double 
vision  or  cataract  formation.  In  cataractous  cases  without 
plus  tension  an  optical  iridectomy,  sphincterectomy,  or  irido- 
tomy  may  give  a  fair  visual  result.  The  iris  may  be  difficult 
to  seize  with  forceps,  but  may  be  drawn  out  with  a  hook. 

In  children  repeated  discission  may  be  preferable  to  extrac- 
tion. On  account  of  the  mobility  of  the  lens,  it  may  be  difficult 
to  make  a  large  enough  opening  in  the  capsule  in  discission, 
and  there  is  some  risk  of  displacement  of  the  lens  backwards 
into  the  vitreous.  For  this  reason  Eversbusch  opened  the 
capsule  with  a  cystitome  introduced  through  a  peripheral 
corneal  puncture. 

Zion*  recommends  transfixion  of  the  lens  with  a  needle 
introduced  from  behind  through  the  sclerotic  to  prevent  its 
displacement  during  discission  by  a  second  needle  introduced 
through  the  cornea. 

Linear  extraction  after  discission  is  inapplicable  because  of 
vitreous  in  the  anterior  chamber.  Terson  recommends  aspira- 
tion with  Bowman's  syringe. 

*  Ophth.  Klinik,  iii  (1899),  121. 


Complicated  and  Soft  Cataracts  379 

In  older  patients  extraction  of  the  lens  in  its  capsule  is 
indicated,  with  loop  or  spoon,  or,  if  the  capsule  be  thickened 
and  opaque,  with  forceps.  L.  Miiller's  or  Bourgeois'  section 
might  be  made.  In  one  case  of  traumatic  subluxation  down- 
wards I  found  the  lens  firmly  adherent  below.  Only  partial 
removal  was  possible.  A  good  deal  of  cortex  was  left  and 
much  vitreous  lost,  and  the  resulting  vision  was  worse  than 
before  operation. 

Where  operation  is  required  on  account  of  double  vision, 
further  lateral  displacement  of  the  lens  with  a  needle  may 
suffice. 

In  a  case  of  ectopia  lentis  with  congenital  coloboma  and 
small  cornea,  the  fellow  eye  was  useless,  and  the  patient 
could  count  fingers  at  3  feet  with  a  4-  6  D  lens.  Though  the 
lens  was  opaque,  I  refused  operation,  fearing  the  loss  of 
vitreous. 


THE    EXTRACTION    OF   SOFT   CATARACT. 

Operation  for  the  removal  of  soft  cataract — z.^.,  opacity  in 
lenses  which  have  not  yet  developed  hard  nuclei — is  per- 
formed mostly  upon  lenses  which  have  been  rendered 
more  or  less  completely  cataractous  by  discission.  The 
treatment  is  usually  for  partial  stationary  cataract,  most 
often  lamellar,  or  for  the  removal  of  the  transparent  lens 
in  high  myopia.  In  other  cases  operation  is  needed  for 
traumatic  cataract,  or  for  ripe  or  overripe  general  cataract 
in  young  persons.  Extraction  must,  however,  be  rejected 
in  favour  of  repeated  needlings  of  cataract  in  young  people 
if  the  cataract  be  complicated,  and  if  at  the  same  time  the 
tension  of  the  eye  be  at  all  reduced,  also  possibly  in  very 
high  myopia.  Traumatic  cataract  in  my  experience  has 
been  practically  always  met  with  at  an  age  when  the  lens 
was  still  fairly  soft  throughout.  There  is  often  inflamma- 
tion, infective  or  otherwise,  which  may  render  considerable 
delay  in  operative  interference  advisable.  The  delay  is 
until  the  eye  has  become  normally  pale,  and  remains  so 


380  Cataract  Extraction 

after  moderate  friction  through  the  Hds.  Operation  may 
be  deferred  also  because  of  unripeness  of  the  cataract. 
But  at  other  times  early  interference  is  necessary  on 
account  of  high  tension  excited  by  the  swollen  and  dis- 
integrating lens.  This  compulsory  removal  of  lens  matter 
is  sometimes  a  supplement  to  discission.  And  it  is  often 
only  a  very  partial  operation,  much  unripe,  sticky  lens 
substance  being  unavoidably  left  behind.  In  other  cases 
extraction  is  an  expeditious  alternative  to  the  very  tedious, 
but  on  the  whole  safer,  absorption  of  the  lens  under 
repeated  needlings. 

The  operation  is   known  as  linear  extraction  (Lanzen- 
extraction),  or    'curette  evacuation.'     It  may  sometimes 


Fig.  96.  Fig.  97. 

Linear  Extraction. 

be  applicable  for  traumatic  cataract  in  people  over  thirty- 
five  years  of  age.  Where  the  lens  has  been  penetrated 
deeply,  the  nucleus  may  become  softened  and  broken  up. 

The  pupil  having  been  dilated  widely,  if  possible,  a 
nearly  straight  incision,  5  to  10  millimetres  long  is  made 
in  the  cornea  with  a  triangular  lance-knife  or  keratome 
The  shorter  section  (with  a  comparatively  narrow  blade) 
is  made  in  infants,  and  also  in  older  patients  if  the  cataract 
is  fully  ripe  or  overripe.  It  is  placed  usually  i  to  1*5  milli- 
metres within  the  corneal  margin.  If  the  capsule  of  the 
lens  has  not  been  opened  previously,  it  is  opened  freely 
now  with  a  cystitome.  If  the  cataract  is  fully  ripe,  depres- 
sion of  the  peripheral  lip  of  the  wound  with  a  curette 
should  enable  most  of  the  soft  lens  matter  to  escape,  with- 


Complicated  and  Soft  Cataracts  381 

out  injury  to  the  iris.  The  material  may  also,  if  necessary, 
be  pressed  out  by  stroking  movements  over  the  cornea 
with  a  tortoise-shell  spoon  or  other  expressor,  the  globe 
being  fixed  by  the  assistant.  The  curette  may  also  be 
inserted  a  little  way  into  the  chamber  to  break  up  and  to 
withdraw  some  of  the  lens  substance.  And  it  is  recom- 
mended sometimes  to  wait  for  the  re-accumulation  of  a 
little  aqueous,  and  to  practise  repeated  reinsertion  of  the 
curette.  (The  instrument  must  be  cleansed  before  each 
reinsertion.)  If  iris  prolapses  early,  it  may  have  to  be 
excised,  but  generally  replacement  suffices. 

The  position  of  the  section  and  other  details  of  the 
operation  vary  with  the  ripeness  of  the  cataract.  If  it  is 
fully  ripe,  the  incision  may  be  placed  in  the  outer  part  of 
the  cornea.  This  is  an  advantage  in  young  children,  as  it 
permits  of  the  operation  being  completed  without  a  general 
anaesthetic,  the  patient  not  being  required  to  look  down. 
But  if  it  is  anticipated  that  a  portion  of  the  lens  is  still 
incompletely  cataractous,  the  incision  should  be  placed 
above.  Probably  an  iridectomy  will  be  required  to 
facilitate  the  evacuation  of  the  chamber,  and  because  of 
bruising  of  the  iris  during  the  manipulation.  Iridectomy 
may  also  be  required  on  account  of  posterior  synechiae. 
The  removal  will  probably  be  incomplete,  and  therefore 
the  wound  may  be  left  occupied  by  shreds  of  translucent 
cortex.  It  may  be  impossible  to  clear  these  shreds  out  of 
the  incision,  where  they  constitute  a  grave  danger,  possibly 
serving  for  the  admission  of  infective  organisms.  There- 
fore the  wound  should  not  only  be  above,  but  it  should  be 
in  the  limbus  and  subconjunctival.  (The  conjunctiva 
should  be  pushed  down  a  little  on  the  point  of  the  kera- 
tome.)  I  have  preferred  to  make  such  a  section  with  a 
narrow  Graefe's  knife,  i  millimetre  or  less  in  breadth. 
Thus  the  incision  can  be  lengthened  a  little  if  desired. 


o 


82  Cataract  Extraction 


That  is,  a  very  shallow  flap  section  may  be  made  instead 
of  the  so-called  linear  section. 

Irrigation  is  often  a  great  help  in  the  removal  of  cortex, 
especially  when  alternated  with  external  pressure,  and  with 
introductions  of  the  curette  to  break  up  the  lens  matter. 
It  is,  however,  better  to  leave  much  of  the  lens  behind, 
and  to  trust  in  atropin  and  mercury  afterwards,  than  to 
continue  in  prolonged  efforts  at  removal.  A  very  partial 
evacuation  suffices  for  the  reduction  of  high  tension.  In 
the  case  of  a  very  overripe  cataract  opaque  capsule  may 
have  to  be  extracted  in  part  or  whole.  Iris  forceps  are 
commonly  suitable. 

As  a  small  modification,  the  lens  capsule  may  be  opened 
with  the  point  of  the  keratome.  But  the  opening  thus 
made  may  be  too  small,  and  if  the  lens  happens  to  be  very 
thin  the  posterior  capsule  may  be  punctured.  The  kera- 
tome may  also  be  used  instead  of  the  curette  for  depres- 
sing the  lip  of  the  wound,  but  care  must  be  taken  in  this 
again  to  avoid  the  posterior  capsule. 

Where  a  general  anaesthetic  is  required,  much  less  of  it 
need  be  used  if  local  anaesthesia  with  cocain  alone,  or  with 
cocain  and  adrenalin,  is  utilized  also. 

Complications. 

1.  Iris  prolapse  is  rare  after  this  operation  because  of 
the  slight  tendency  to  gaping  of  the  section,  and  because  iri- 
dectomy is  often  performed  at  the  time  of  the  extraction. 

2.  Vitreous  may  prolapse  during  operation  through 
puncture  of  the  posterior  capsule  with  the  point  of  the 
knife,  or  in  breaking  up  lens  matter  with  the  curette,  or 
owing  to  the  extraction  of  opaque  capsule,  or  possibly,  in 
cases  of  traumatic  cataract,  through  the  injury  already 
sustained  by  the  eye. 

3.  Unripe   lens    matter   left  behind   may  give   rise   to 


Complicated  and  Soft  Cataracts  38 


J 


trouble,  either  alone  or  adding  to  the  work  of  infective 
organisms. 

4.  Infection  may  be  introduced  through  a  purely  corneal 
wound,  kept  open  by  shreds  of  lens  substance,  by  capsule, 
or  by  vitreous. 

In  India  we  meet  fairly  often  with  a  class  of  patient  for 
whom  neither  extraction  nor  simple  discission  is  quite 
applicable.  The  patients  are  children  with  overripe 
cataracts  dating  generally  from  infancy.  There  is  usually 
much  irregular  anterior  capsular  opacity,  and  enclosed  in 
the  sac  is  only  a  thin  layer  of  milky  fluid,  sometimes  with 
a  few  small  flakes  of  cortex  or  granular  debris.  What  is 
required  is  discission,  plus  evacuation  of  the  fluid  and 
cortical  remains.  A  wide  and  satisfactory  opening  in  the 
opaque  membrane  can  be  secured  by  the  use  of  two 
Bowman's  stop-needles.  But  if  any  of  the  turbid  fluid  be 
left  behind,  there  is  a  liability  to  an  acute  glaucomatous 
attack  setting  in  within  a  few  hours.  We  found  this  by 
experience,  and  we  found  that  relief  of  the  tension  followed 
at  once  upon  evacuation  of  the  chamber  through  a  small 
puncture.  The  complication  was  afterwards  prevented  by 
removing  the  fluid  completely  immediately  after  opening 
the  capsule.  This  is  done  by  a  subconjunctival  puncture 
at  the  limbus  with  a  narrow  (i  millimetre)  Graefe's  knife. 
Even  with  the  eye  soft  from  leakage  through  needle 
punctures,  the  narrow  knife  can  be  introduced  without 
much  pressure.  The  puncture  is  enlarged  to  about  double 
the  width  of  the  blade,  and  the  latter  rotated  in  the  wound, 
and  the  iris  pressed  a  little  backwards  until  the  milk 
leaks  gradually  away.  The  knife  is  passed  in  front  of  the 
iris  to  the  neighbourhood  of  any  milky  or  granular  remains, 
and  then  by  intermittent  jerky  pressure  serves  as  a  director 
for  the  gradual  passage  outwards  of  the  material.     If  by 


384  Cataract  Extraction 

chance  both  layers  of  capsule  are  punctured  by  the  needles 
so  that  vitreous  is  a  little  displaced  forwards,  this  inter- 
feres but  little  with  the  evacuation,  though  it  may  delay  it 
a  little.  It  is  very  satisfactory  to  note  how  patient  con- 
tinuance of  the  jerky  pressure  upon  the  iris  gradually 
directs  piece  after  piece  of  soft  cortex  along  the  blade  and 
through  the  puncture.  Chloroform  is  seldom  needed  even 
in  young  children,  if  the  head  be  held  firmly.  There  is 
practically  no  pain.  The  assistant  fixes  the  eye  and 
rotates  it  for  the  insertion  of  the  needles. 

Linear  extraction  of  the  opaque  capsule  and  of  its 
contents  is  quite  unsuitable  at  the  early  age  of  most  of 
these  patients,  even  with  a  subconjunctival  wound. 
Vitreous  is  almost  sure  to  enter  the  wound,  and  the 
healing  of  the  latter  is  further  interfered  with  by  rubbing 
the  eyes  and  by  contraction  of  the  lids,  thus  predisposing 
to  infection. 

SUCTION  (ASPIRATION)  OF  SOFT  CATARACT. 

A  brief  reference  is  due  to  the  removal  of  soft  lens  matter 
through  a  linear  wound  by  suction,  a  method  known  of  old  to 
the  Arabs  and  Persians,  and  associated  in  its  later  develop- 
ment with  the  names  of  two  Englishmen.  Teale's  ■'•  cannula 
for  suction  by  the  mouth  and  Bowman's  pump  for  instrumental 
aspiration  have  been  very  generally  used.  The  method — 
recommended  by  Terson  (pere)  for  subluxated  traumatic 
cataracts  in  young  subjects,  and  advantageous  in  quite  young 
children,  owing  to  the  small  size  of  the  incision  (less  than 
5  millimetres)  required— has  fallen  into  disuse,  apparently 
from  its  very  limited  field  of  usefulness.  In  older  patients  it 
offers  no  especial  advantages.  Owing  to  the  liability  of  the 
cannula  to  become  blocked,  it  is  suitable  only  for  quite  ripe 
cataracts,  which  are  readily  removable  without  suction.  In 
suction  by  the  mouth — the  older  method — the  degree  of  force 
employed  could  be  regulated  to  a  greater  nicety.     And  very 

*  R.  L.  O.  H.  Rep.,  iv,  2,  197  ;  and  The  Lancet,  1880,  i,  29. 


Complicated  and  Soft  Cataracts  385 

slow  removal  of  the  lens  matter  was  insisted  upon  to  prevent 
complications,  such  as  bleeding  from  the  iris,  indrawing  of  iris 
into  the  opening  of  the  cannula,  rupture  of  posterior  lens 
capsule,  and  presentation  of  vitreous.  The  tough  capsules  of 
some  congenital  cataracts,  insufficiently  opened,  and  therefore 
not  easily  penetrated  by  the  cannula,  sometimes  led  to  dis- 
placement of  the  lens.  The  capsule  was  sometimes  opened  by 
preliminary  discission,  at  other  times  by  the  broad  needle  or 
keratome,  after  the  making  of  the  small  corneal  section.  Sub- 
sequent infective  inflammations  were  probably  attributable  to 
want  of  sterilization  of  the  instruments  employed. 


25 


INDEX 


'  Adherent  conjunctival  flap  '  ope- 
ration, 203 
Adhesion  of  iris  to  cicatrix,  156 
Adrenalin  instillation,  53,  223 
After-cataract,  1,  321 

capsular,  321 

complicated,  324,  351 

excision  of,  359 

extraction  of,  360 

treatment  of,  325 
After-treatment,  149,  155 
Age  of  patients,  18 

extreme  old,  17 
Agnew's  method  of  needling,  357 
Air-bubble  in  anterior  chamber,  134 
Albuminuria,  17 
Amblyopia  from  disuse,  159 
Anaemia,  extreme,  17 
Anaesthesia,  52 

general,  182 
Angelucci's  fixation,  188 
Anteflexion  of  corneal  flap,  293 
Anterior  chamber  shallow,  67,  68, 

70,  82,  83,  84,  344,  365 
Aqueous,  early  loss  of,  69,  85 
Artificial  ripening,  19 
Asepsis,  266 
Astigmatism,    post-operative,    157, 

196,  301 
Atropin  instillation,   146,   156,  289, 

308 
Attendant,  the  irrigator,  59 

B 


Bacteria,  conjunctival,  185,  271 
Bandaging,  148 
Beer's  knife,  23 
Black  cataract,  9 
Bleeding  from  iris,  98 

into  anterior  chamber,   74,  83, 
104.  134,  307 
Blue  vision,  159 
Bourgeois'  operation,  200 
Bronchitis,  17 
Buttonholed  iris,  97,  231 


Capsular  after-cataract,  321 

cataract,  i 

incisions,  various,  no 

plague,    anterior,  9,   112,    123, 
264 
Capsule,  extraction  of  anterior,  238 

extraction  of,  265,  362 

forceps,  34,  239 
Panas' ,  362 

incarceration  of,  83,   142,   143, 
307,  316 

opacity  of,  5,  6,  in,  112,  123, 
240,  264 

puncture  of  posterior,  242 

replacement  of,  142 

rupture  of,  258 
Capsulotomy,  loi 

incomplete,  122 

peripheral,  236 

preliminary,  238 

with  the  knife,  237 
Cataract,  after-,  i,  321 
capsular,  321 

black,  9 

capsular,  i 

complicated,  2,  10 

incipient,  3 

infantile,  19 

liquefying,  4 

previously  Morgagnian,  6,  113, 
123,  264 

Morgagnian,  5,  in,  122,  264 

overripe,  3,  5,  8,  iii,  250,  264, 

383 

primary,  2 

ripe,  3,  5,  8 

secondary,  2,  369,  370 

shrinking,  7 

soft,  extraction  of,  379  ,, 

suction  of,  384 

traumatic,  2,  10 

unripe,  3,  5,  7.  ".  323 

with  glaucoma,  365 
Cataracta  accreta,  370 
Chibrefs  double-current  syringe,  41 

3^7  25—2 


;88 


Index 


Choroidal  detachment,  312 
Cicatrix,  cystoid,  300 

fistulous,  300 
Clark's  speculum,  29 
Cleansing  of  conjunctiva,  59,  144, 
183,  273 

of  lids,  179 
Cocain  instillation,  52 
Collapse  of  cornea,  131 

of  globe,  132 
Combined  operation,  the,  62,  216 
Complicated  after-cataract,  324,  351 

cataract,  2,  10 
Conjunctival  bacteria,  185s  271 

cleansing,  59,  144,  183,  273 

flap,  the,  63,  71,  74,  79,  95,191 
adherent,  203 

folding,  76 

tearing,  77 
Contact  keratitis,  292 
Corneal  collapse,  131 

drying,  61 

epithelium,  exfoliation  of,  293 

flap,  eversion  (anteflexion)  of, 

293 
margin,  the,  64 
opacity,  15,  291 
linear,  292 
Cortex  left  behind,  219,  323 

removal  of,  135,  226 
Counter-puncture,  the,  68 
Curette,  the,  38 
Cyanopsia,  159 
Cystitomes,  34 
Cystoid  cicatrix,  300 
Czermak's   operation,  61,   79,  206, 
375 

D 

daGama  Pinto's  needling,  350 
Dacryocystitis,  15 
David's  operation,  23 
de  Wecker's  scissors,  34 

section,  28 
Delayed  union,  308 
Delivery  of  the  lens,  114,  226 
Dermatitis,  acute,  295 
Desmarres'  retractors,  31,  90,  187 
Detachment  of  choroid,  312 

of  retina,  175,  331,  364 
Diabetes,  17 
Discission,  19,  331,  339,  348,  354 

posterior  scleral,  350 

with  scissors,  357 
Discoid  lenses,  8,  125 
Dislocated  lenses,  375 
Displacement  of  lens  upwards,  116, 
117 


Distortion  of  pupil,  173,  300 
Double  extraction,  16 

needle  operation,  354 
Downward  section,  197,  206 
Dressing,  the,  146 

hollow,  248 

test,  44,  180 


Early  exudations,  285 
Entropion,  spastic,  295 
Epilation,  180 
Erythropsia,  159 

Escape  of  vitreous,  164,  220,  257, 
306 
causes  of,  166 
consequences  of,  171 
management  of,  170 
percentage  of,  169 
prevention  of,  168 
Eserin  instillation,  230 
Eversion  of  corneal  flap,  293 
Excision  of  after-cataract,  359 
Exfoliation  of  corneal  epithelium. 

Expression  of  Meibomian  secretion, 

56,  181 
Expressors,  lens,  36 
Expulsive  haemorrhage,  16,  160 


Fellow  eye,  the,  16 
Filamentous  keratitis,  293 
Filtration  oedema,  153 
Finger  separation  of  lids,  90,  187 
Fistulous  cicatrix,  300 
Fixation,  65,  76,  92,  188 

Angelucci's,  188 

forceps,  32 
Flap,  the  conjunctival,  63,  71,  74, 

79.  95,  191 
Flatulent  distension  of  the  abdomen. 

Folding  of  conjunctiva,  76 

of  capsule,  34,  239 
Forceps,  fixation,  32 

iris,  33 
Fornices  retracted,  61,  71,  76,  87 
Forster's  ripening,  20 


Galezowshi' s  needling,  353 
Gaping  of  the  wound,  80,  153 
Glaucoma,  cataract  with,  365 

secondary,  218,  301,  314,  330 


Index 


;89 


H 

Haab's  needling,  352 
Haemorrhage,  expulsive,  16,  160 

from  iris,  98 

into  anterior  chamber,  74,  83, 
104,  134,  307 
Hand,  support  of  the,  67,  75 
Heahng  of  the  wound,  115 
High  myopia,  extraction  in,  372 
Hypersclerosis,  9 

I 

Impaction  of  capsule  and  iris.     See 

Incarceration 
Incarceration  of  capsule,  83,    142, 
143.  307,  316 
of  iris,  83,   96,    172,   217,   259, 

295,  316 
of  vitreous,  164,  171 
Incomplete  capsulotomy,  122 
Infantile  cataract,  19 
Infection  of  the  eye,  172,  244,  266, 

299,  327 

late,  288 

localized  v^found,  287 

salivary,  178 
Infective  processes,  the,  281 

results,  269 
Instillation  of  adrenalin,  53,  223 

of  atropin,  146,  156,  289,  308 

of  cocain,  52 

of  eserin,  230 
Intracapsular  extraction,  249 
Intraocular    irrigation,    137,    243, 

382 
Iridectomy,  the,  91 

peripheral,  231,  232 

preliminary,  20,  234 
Irido-cyclitis,  283 
Iridotomy,  232 
Iris,  adhesion  of,  to  scar,  156 

buttonholed,  97 

cut  by  the  knife,  84 

forceps,  33 

incarceration    of,    83,    96,    172, 
217,  259,  295,  316 

prolapse  of,  77,  85,  86,  217,  259, 
295 
treatment  of,  302 

replacement  of,  141,  228 

repositors,  38 

scissors,  34 
Iritis,  262,  283,  286,  315,  346 
Irrigation,  intraocular,    137,   243, 
382 

perchloride  (sublimate),  13,  51, 
58,  183,  269 
Irrigators,  39 


Jackson's,  Edward,  needling,  349 
Jacobson's  section,  24 

K 

Keratitis,  contact,  292 

filamentous,  293 

striped,  291 
Knapp  on  capsulotomy,  106 
Knapp's  knife-needle,  336,  348 
Knife,  von  Graefe's,  33  "■ 

narrow,  336,  339 
Kugel's  needling,  353 
Kulint's  needling,  350 


Lacrymal  passages,  14 

Lashes  cut  short,  61 

Lebrun's  section,  27 

Left-handed  cutting,  76 

Lid-margins,  179 

Lids,  cleansing  of,  179 

separation   of,   by  fingers,  90, 
187 

Liebreich's  section,  27 

Linear  extraction,  18,  372,  380 

Liquefying  cataract,  4 

Loss  of  aqueous,  early,  69,  85 

of  vitreous,  164,  220,  257,  306 
causes  of,  166 
consequences  of,  171 
management  of,  170 
percentage  of,  169 
prevention  of,  168 

Lower  section,  197,  206 

M 
McKeown's  irrigator,  39 
Meibomian  secretion,  expression  of, 

56,  181 
Mellinger's  speculum,  29 
Mental  disturbance,  313 
Modified  linear  extraction,  25 
Morgagnian   cataract,  5,  iii,   122, 
264 
previously,  6,  113,  123,  264 
Mouth-screen  (mask),  the,  55,  178 
Micller's  section,  201 
Myopia,  extraction  in  high,  372 

N 

Needle,  Knapp's  knife-,  336,  348 
NeedUng,  326,  339,  348,  354 

early,  332 

preliminary,  18,  19 
Nervous  patients,  43,  61,  89,  105, 
168 


390 


Index 


o 

CEdema,  filtration,  153 

Old  age,  extreme,  17 

Opacity,  corneal,  15,  291 

Opaque  capsule,  5,  6,  112,  123,  240, 

264 
Open  treatment  of  the  wound,  247 

modified,  248 
Operability,  11 
Orbicularis    spasm,    89,    150,    186, 

187,  297 
Outer  sections,  199 
Overripe  cataract,  3,  5,  8,  iii,  250, 

264,  283 

P 

Panas'  capsule  forceps,  362 
Palpebral  aperture  contracted,  71 
Paracentesis,  subconjunctival,  368 
Perchloride  irrigation,   13,  51,  58, 

183,  269 
Peripheral  capsulotomy,  236 

iridectomy,  231,  232 

linear  extraction,  25 
Pigmentation  of  cicatrix,  154 
Plehn's  section,  201 
Preliminary  capsulotomy,  238 

iridectomy,  20,  234 

needling,  18 
Preparation  of  the  patient,  43 
Prolapse  of  iris,  77,  85,  86,  217,  259, 
295 
treatment  of,  302 

of  vitreous,  164,  170,  306 
Puncture,  the,  67 
Pupil,  distortion  of,  173,  300 

reaction  of,  12 

sphincter  of,  96,  97 

R 

Red  vision,  159 
Removal  of  cortex,  135 
Reopening  of  the  wound,  308 
Replacement  of  capsule,  142 

of  iris,  141,  228 
Repositors,  iris,  38 
Respirators,  55,  178 
Results,  bad,  277 

infective,  269 

visual,  159,  278 
Retinal  detachment,  175,  331,  364 
Retracted  fornices,  61,  71,  76,  87 
Retractors,  Desmarres' ,  31,  90,  187 
Ripening,  artificial,  19 
Rocking  motion  of  the  knife,  71 
Rupture  of  capsule,  258 

of  zonule,  74,  125 


!  ^ 

I    Salivary  infection,  178 

Sawing  action  of  the  knife,  71 
I   Schulek's  section,  201 
!    Scissor  discission,  357 
Scissors,  iris,  34 
Sclero-corneal  section,  62,  195 
Secondary  cataract,  2,  369,  370 

glaucoma,  218,  301,  3:4,  330 
Section,  the,  62,  189 

de  Wecker's,  28 

downward,  197,  206 

Jacobson's,  24 

Lebrun's,  27 

Liebreich's,  27 

Miiller's,  201 

Plehn's,  201 

purely  corneal,  196 

outer,  199 

sclero-corneal,  62,  195 

size  of,  77 

too  small,  78,  121 

too  peripheral,  83 

von  Arlt's,  27 

von  Graefe's  peripheral  linear,  25 
Sedative  draught,  46 
Self-control,  the  patient's,  43,  105, 

129 
Separation   of  lids  by  fingers,  90, 
187 

of  the  wound,  80,  153 
Shallow  anterior  chamber,  67,  68, 

70,  82,  83,  84,  344.  365 
Shrinking  cataract,  7 
Simple  extraction,  216 

linear  extraction,  24 
Size  of  section,  77 
Skopomorphin,  183 
Slack  eyes,  131 
Smith's  operation,  253 
Soft  cataract,  extraction  of,  379 

suction  of,  384 
Soiling  of  the  knife,  70 
Spasm  of  orbicularis,  89,  150,  186, 

187,  297 
Spastic  entropion,  295 
Speculum,  the,  28,  60,  88,  144,  186 
Sphincter  of  pupil,  96,  97 
Sphincterectomy,  99 
Spoons,  38 

Sterilization  of  instruments,  47 
Stilling's  harpoon  needles,  356 
Stop-speculum,  the,  28,  60,  88,  144, 

186 
Striped  keratitis,  291 
Stupid  patients,  44,  89 
Subconjunctival  extraction,  61,  79, 
202,  375 


Index 


391 


Subconjunctival  paracentesis,  368 
Sublimate   irrigation,    13,    51,    58, 
183,  269 

Subluxated  lenses,  378 
Suction  operations,  384 
Suppurations,  282 
Suture  of  wound,  213 

of  conjunctival  flap,  215 
Sympathetic  ophthalmia,  16,  287 
Syphon-douche,  the,  137 
Syringe,    Chibret's    double-current, 

T 

Tearing  of  conjunctiva,  77 
Tension,  vitreous,  130 
Test  dressing,  the,  44,  180 
Toilet  of  the  eye,  133 
Traumatic  cataract,  2,  10 
Tremor  of  lens,  6 

U 

Union,  delayed,  308 
Unripe  cataract,  3,  5,  7,  11,  323 
Upward  displacement  of  the  lens, 
116,  117 


Vectis,  the,  37 
Visual  results,  159,  278 
Vitreous,  escape  of  (loss  of),  164, 
220,  257,  306 
causes  of,  166 
consequences  of,  171 
management  of,  170 
percentage  of,  169 
prevention  of,  168 
incarceration  of,  164,  171 
prolapse  of,  164,  170,  306 
tension,  130 
Volume  of  cataractous  lenses,  21 
von  Arlt's  section,  27 
von  Graefe's  knife,  33 

narrow,  336,  339 
modified  linear  extraction,  25 

W 
Weber's  knife,  26 
Wenzel's  operation,  371 
Wolffberg's  kalorisator,  20 


Zonule,  rupture  of,  74,  125 


Bailliire,  Tindall  (5r>  Cox,  8,  Henrietta  Street,  Cement  Garden 


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